UNIVERSITY  OF  CALIFORNIA 
AT   LOS  ANGELES 


GIFT  OF 

David  D.   Thornton 


The  Treatment  of 
War  Wounds 


By 

W.W.  Keen,M.D.,LL.D. 

Emeritus  Professor  of  Surgery 

Jefferson  Medical  College,  Philadelphia 

Major,  Medical  Reserve  Corps,  U.  S.  Army 

* 

Illustrated 


Philadelphia  and  London 

W.  B.  SAUNDERS  COMPANY 

1917 


Published  August,  1917 


Copyright,  1917,  by  W.  B.  Saunders  Company 


Reprinted  December,  1917 


PRINTED   IN  AMERICA 


5 


\!$v 


PREFATORY  NOTE 

This  Report  has  been  much  delayed  by  circum- 
stances beyond  my  control.  Happily  the  delay  has 
had  its  compensations,  as  I  have  been  enabled  to  add 
important  matter  from  the  large  experience  of  several 
able  surgeons  actually  in  the  conflict.  I  have  been 
enabled  also  to  include  the  work  on  Acriflavine,  Pro- 
flavine  and  Brilliant  Green  (p.  162),  Mercurophen, 
and  the  latest  technic  on  the  Paraffin  Treatment  of 
Burns,  etc.,  which  were  not  published  until  recently. 

But  more  especially  am  I  gratified  to  be  able  to 
add,  as  the  Report  is  passing  through  the  press,  two 
most  important  contributions  to  our  knowledge  —  one, 
the  new  antiseptic,  Dichloramin-T,  and  the  simplified 
technic  of  Dakin  for  the  treatment  of  infection  in 
wounds;  and  the  other  the  most  welcome  announce- 
ment of  an  antitoxin  against  gas  gangrene.  This  will 
be  indeed  a  boon  to  many. 

I  should  have  quoted  Carrel  and  Dehelly  (Le 
Traitement  des  Plaies  infectees)  and  Dumas  and 
Carrel  (Pratique  de  1'Irrigation  des  Plaies  dans  la 
Methode  du  Docteur  Carrel)  directly,  but  unfortu- 

7 

353794 


8  PREFATORY  NOTE 

nately  I  was  not  able  to  obtain  copies  of  these  books 
until  just  after  I  had  completed  the  text.  I  have, 
however,  been  able  to  utilize  some  cuts  from  Carrel 
and  Dehelly  by  the  kind  permission  of  the  authors  and 
of  Messrs.  Masson  &  Cie,  of  Paris.  I  have  reproduced 
some  illustrations  from  the  British  Medical  Journal 
of  June  9,  1917,  from  a  paper  by  Bowlby.  The  editor 
of  the  Journal  gave  his  permission  to  use  these,  but 
I  had  to  assume  that  of  Sir  Anthony,  as  it  was  im- 
possible to  wait  for  his  permission.  I  have  also  to 
thank  Colonel  Thomas  H.  Goodwin,  of  the  British 
Army,  and  the  Editor  of  the  Journal  of  the  American 
Medical  Association,  for  permission  to  use  Fig.  2,  the 
diagram  from  Colonel  Goodwin's  paper. 

WILLIAM  W.  KEEN 


CONTENTS 


PAGl 


RESPECTS  IN  WHICH  PRESENT  WAR  DIFFERS  FROM  PRE- 
VIOUS WARS 11 

Huge  Numbers,  13;  New  Means  of  Transportation, 
16;  New  Weapons,  28;  Rampant  Infection  of 
Wounds  and  New  Methods  of  Conquest  of  Infection, 
29. 

THE  DAKIN-CARREL  METHOD 40 

Preparation  of  the  Solution,  41;  Necessary  Materials, 
46;  Operative  Technic  to  Prepare  the  Wound,48;  In- 
troduction of  the  Instillation  Tubes,  50;  After-care 
of  the  Wounds,  53;  Bacteriologic  Examination  of  the 
Wound,  54;  Reunion  of  Wound,  55;  Curve  of  Healing, 
58;  Objections  to  Method,  60;  Dichloramin-T,  61. 

REMOVAL  OF  FOREIGN  BODIES 68 

Stereo-fluoroscopy  in  the  Localization  and  Extraction 
of  Foreign  Bodies,  68. 

TETANUS 74 

Memorandum  on  Tetanus  Issued  by  the  British  War 
Office  Committee,  77;  the  Method  of  Performing  an 
Intrathecal  Injection,  87. 

GAS  INFECTION  AND  GAS  GANGRENE 89 

An  Antitoxin  to  Prevent  Gas  Gangrene,  95. 

W'OUNDS  OF  THE  HEAD 100 

WOUNDS  OF  THE  CHEST 110 

WOUNDS  OF  THE  JOINTS 112 

ABDOMINAL  WOUNDS 115 

BURNS 122 

9 


10  CONTENTS 


SOME  PERSONAL  LETTERS 126 

Letter  from  Dr.  Joseph  A.  Blake,  126;  Letter  from  Sir 
Anthony  A.  Bowlby,  Bart.,  128;  Letter  from  Dr.  Hugh 
Cabot,  133;  Letter  from  Dr.  George  W.  Crile,  143; 
Letter  from  Dr.  Harvey  Gushing,  144;  Letter  from  Dr. 
Charles  L.  Gibson,  148;  Letter  from  Dr.  Henry  H.  M. 
Lyle,  152;  The  Treatment  of  Gunshot  Wounds,  by  Sir 
Berkeley  Moynihan,  154;  Letter  from  Dr.  Fred.  T. 
Murphy,  155. 

APPENDIX 160 

The  Use  of  Glue  Adhesive  for  the  Application  of  Ex- 
tension in  Fractures,  160;  Acriflavine,  Proflavine,  and 
Brilliant  Green,  162. 


INDEX. .  .165 


THE  TREATMENT  OF  WAR 
WOUNDS 

This  Report  has  been  compiled  at  the  request  of  the 
National  Research  Council,  and  especially  of  its  Medi- 
cal Committee,  of  which  Dr.  Victor  C.  Vaughan  is 
Chairman.  It  does  not  pretend  to  be  complete,  but  is 
only  a  memorandum  on  some  of  the  more  important 
and  most  recent  improvements  in  the  treatment  of 
war  wounds. 

Unfortunately,  my  knowledge  is  necessarily  second- 
hand, as  I  have  been  unable  to  visit  the  hospitals  in 
Europe;  but  the  letters  from  a  number  of  my  friends 
who  have  had  first-hand  experience,  which  I  solicited 
and  print  herewith,  are  most  valuable  documents, 
covering  a  number  of  subjects  of  importance:  some 
of  them  medical,  besides  war  wounds  proper.  My 
hearty  thanks  are  tendered  to  them,  especially  to 
those  who  have  taken  time  in  their  overworked  lives 
to  furnish  this  valuable  information.  Theirs  is  indeed 
first-hand  knowledge.  In  a  few  pregnant  sentences 
they  express  convictions  which  are  the  result  of  hard 
and  sometimes  bitter  experiences  of  months  and  even 

11 


12  TREATMENT  OF  WAR  WOUNDS 

years  of  warfare.    Even  in  those  letters  differences  of 
opinion  are  seen. 

From  the  surgical  point  of  view,  the  present  war 
differs  widely  from  any  preceding  wars  in  five  prin- 
cipal respects: 

(1)  The  huge  numbers  in  the  armies  and,  therefore, 
of  the  wounded. 

(2)  The  new  means  of  transportation. 

(3)  The  new  weapons,  especially  in  the  artillery. 

(4)  Rampiant  infection  of  wounds. 

(5)  The  conquest  of  infection  by  more  efficient 
antiseptics  and  by  new  methods. 

In  two  additional  respects  also  great  progress  has 
been  made: 

(a)  The  reconstructive  surgery  of  the  face  and 
jaws  by  the  cooperation  of  the  dentist  and  the  sur- 
geon, and  (b)  the  great  development  of  war  ortho- 
pedics and  the  training  of  disabled  soldiers.  These 
two  topics  I  must  omit. 

I  should  also  call  attention  to  one  strange  means 
of  preventing  wounds,  which,  though  neither  surgical 
nor  medical,  yet  is  of  great  practical  value. 

We  are  apparently  returning  to  the  use  of  steel 
armor,  as  in  the  middle  ages.  Light  steel  helmets  and 
to  some  extent  corselets  over  the  chest  have  undoubt- 


HUGE  NUMBERS  OF  WOUNDED  13 

edly  lessened  to  a  very  appreciable  extent  wounds  of 
the  head  and  the  thoracic  viscera.  In  trench  warfare 
the  head  is  especially  exposed,  and  here  the  helmet 
has  found  its  chief  use. 

1.  The  huge  numbers  in  the  contending  armies 
cause  sudden  flooding  of  the  hospitals,  especially 
those  near  the  front,  with  enormous  numbers  of  the 
wounded  after  each  "drive"  or  assault.  Thus  a  hos- 
pital with  300  or  400  beds  may  suddenly  be  over- 
whelmed by  1000  or  more  cases. 

It  is  often,  therefore,  physically  impossible  to  give 
speedy  and  thorough  treatment  to  all.  A  single  case, 
even  if  it  urgently  requires  attention, — if  this  will 
absorb  a  long  time, — may  have  to  wait,  for  in  that 
same  time  a  dozen  others,  almost  equally  exigent,  but 
requiring  less  time,  might  be  cared  for.  The  greatest 
good  of  the  greatest  number  must  be  the  rule.  On 
the  other  hand,  an  abdominal  case  or  a  case  of  inter- 
nal hemorrhage,  even  if  it  does  involve  time,  must 
have  precedence  of  a  dozen  who  can  wait.  The 
surgeon's  good  judgment  must  be  his  constant 
guide. 

For  the  same  reason,  and  for  want  of  the  needed 
aseptic  conditions,  few  abdominal  cases  and  few  if 
any  injuries  involving  the  brain  should  be  operated 
on  near  the  front.  Shock  from  severe  wounds  and 


14  TREATMENT  OF  WAR  WOUNDS 

hemorrhage  always  must  take  precedence  of  every- 
thing else. 

Porter,*  in  a  graphic  and  illuminating  report  on 
"Shock  at  the  Front,"  from  observations  made  as 
perilously  near  as  within  38  meters  of  the  German 
trenches,  has  especially  called  attention  to  the  great 
saving  of  life  which  would  result  if  the  same  means 
which  have  been  proved  effective  in  experimental 
research  in  animals  were  adopted  in  man.  His  sum- 
mary of  these  procedures  is  as  follows: 

(1)  A  special  position  of  the  wounded — the  ab- 
dominal vessels  should  be  higher  than  the  heart  and 
the  brain. 

(2)  Heat. 

(3)  Intravenous  injections  of  normal  saline  solu- 
tion. 

(4)  Intravenous  injections  of  adrenalin. 

(5)  The  transfusion  of  blood  in  certain  cases. 

(6)  The  taking  of  the  diastolic  pressure  every  half- 
hour. 

Some  of  these  procedures  will  require  but  little 
time.  Even  the  diastolic  pressure,  which  in  severe 
cases  should  be  recorded  at  the  earliest  possible  mo- 
ment, he  says  can  be  taken  by  the  auscultatory 
method  in  two  minutes.  The  chief  drawback  is  that 
*  Boston  Med.  and  Surg.  Jour.,  December  14,  1916. 


TREATMENT  OF  SHOCK  15 

at  first  it  must  be  taken  every  half -hour.  But  the 
results  prove  it  to  be  time  well  spent,  for  "men  who 
looked  like  cadavers  and  were  almost  pulseless  came 
back  to  life  and  after  two  hours  " —requiring  only 
three  or  four  observations,  be  it  noted—  "  talked  pleas- 
antly of  their  children."  A  well-trained  nurse  or  an 
intelligent  orderly  can  attend  to  some  of  these  details 
and  so  free  the  surgeon. 

Bowlby  calls  attention  to  the  fact  that  the  wounded 
will  often  have  suffered  from  loss  of  blood,  loss  of 
sleep,  insufficient  food,  and  exposure  to  cold,  and  if 
to  these  are  added  severe  pain  and  the  exhaustion  due 
to  an  unavoidable  jolting  transportation,  they  will  be 
on  the  verge  of  collapse.  The  first  needs  of  such  a 
man  are  rest,  warmth,  and  food,  of  which  the  first 
two  are  the  most  important.  These  restoratives  may 
easily  be  required  before  any  treatment  (save  for 
hemorrhage)  should  be  attempted.  "The  more  ex- 
perienced the  surgeon,  the  less  is  he  likely  to  hurry  on 
a  severe  primary  amputation."  Threatened  gas  gan- 
grene or  rapidly  spreading  sepsis  may  force  his  hand. 
Much  discretion,  therefore,  must  be  allowed  the  sur- 
geon. 

Archibald  and  Maclean*  emphasize  the  need  for 
warmth  by  stating  that  in  their  cases  of  profound 
*  Trans.  Amer.  Surg.  Assoc.,  1917. 


16  TREATMENT  OF  WAR  WOUNDS 

shock  the  ordinary  clinical  thermometer  did  not  reg- 
ister low  enough,  as  in  some  of  their  cases  the  tem- 
perature was  below  92°  F.  G.  Holmes,  in  injuries  of 
the  cord  at  the  sixth  to  the  eighth  cervical  segments, 
has  observed  temperatures  of  80°  F.,  yet  the  patients 
survived  for  several  days. 

2.  The  new  means  of  transportation  by  automo- 
bile has  helped  enormously.  While  the  wounded  must 
often  lie  for  hours  and  sometimes  days  in  the  "No 
Man's  Land"  between  the  opposing  trenches,  and  the 
removal  of  the  wounded  must  be  done  largely  at 
night,  yet,  on  the  whole,  often  they  have  been  brought 
to  hospitals,  as  at  La  Panne  to  Depage,  and  at  Com- 
piegne  to  Carrel,  within  a  few  hours.  Later,  attention 
will  be  called  to  the  rapidity  with  which  infection 
spreads,  and  therefore  the  overwhelming  importance 
of  the  earliest  possible  removal  of  the  wounded  to 
hospitals,  where^trejanus,  gas  infection,  and  other  in- 
fections can  be  prevented,  ameliorated,  or  cured. 

Hence  the  means  of  quick  transportation  are  so 
important  that  I  have  included  this  as  seriously  con- 
tributing to  the  proper  wound  treatment.  The  dia- 
gram on  page  18,  kindly  furnished  me  by  Colonel  Henry 
Page,  of  the  United  States  Army  Medical  Service, 
shows  at  a  glance  the  scheme  of  the  American  army, 
the  different  zones  of  collection,  evacuation,  distri- 


LOCATION  OF  AMERICAN  HOSPITALS          17 

bution;  the  various  kinds  of  hospitals;  the  personnel 
which  serves  these  hospitals,  and  the  means  of  trans- 
portation in  each  zone.  This  will  save  a  long  descrip- 
tion. Compare  the  diagrams  on  pages  18  and  19. 

It  should  be  noted,  as  pointed  out  by  Colonel  Page, 
that  this  plan  of  charging  the  Medical  Department 
with  the  orderly  transportation  of  the  wounded  from 
the  front,  where  they  were  a  burden  to  the  fighting 
forces  and  where  surgical  treatment  was  impossible, 
to  where  such  treatment  was  possible,  is  due  to 
the  foresight  and  administrative  ability  of  Jonathan 
Letterman,  my  old  Chief  and  Medical  Director  of 
the  Army  of  the  Potomac  in  1862.  He  was  one  of 
the  remarkable  military  medical  men  developed  by 
the  Civil  War. 

By  the  kind  permission  of  Colonel  Thomas  H. 
Goodwin,  C.M.G.,  D.S.O.,  of  the  Medical  Service 
of  the  British  Army,  and  of  the  editor  of  the  Journal 
of  the  American  Medical  Association  (July  14,  1917), 
I  am  enabled  to  add  a  corresponding  diagram  show- 
ing the  relation  of  similar  hospitals  in  the  British 
Army.  The  average  distances,  Colonel  Goodwin 
states,  are  as  follows:  The  "Regimental  Medical 
Officer"  will  be  about  500  yards  behind  the  front 
trenches,  further  back,  in  succession,  to  the  "ad- 
vanced dressing  stations"  will  be  half  a  mile  to  a 

2 


18 


TREATMENT  OF  WAR  WOUNDS 


ZONES  OF  COLLECTION,  EVACUATION,  AND  DISTRIBUTION 
IN  THE  UNITED  STATES  ARMY 


FIRING    LINE. 


<$TA  TIOMfOflMfD  BY 
J\  ffegimental  personnel 


1st  AID 


DRESSING 


\  Ambulance  Co. 

...  (Dressino  Statin" 
\      section) 

N  Field  Hospital  Co.  FIELD 


END  OFCOLLECTMG 


Hasp.  Co.  EVACUATE 


BASE 


£W>  OFEVACUA  T7NG  ZONE 


How  TRANSPORTED 

By  regimental  personnel  on  lifters 


STATION 


By  BEARER  SECTION-Ambulance  Co. 
on  inters 


STATION 


By  WHEEL  SECTION-Ambulance  Co 
mule  or  motor  ambulances 


HOSPITAL 


ZONE-  (This  /s/he  begmnmgoffhe 


BEGINNING  OF  THE m  CUATION*-'ne  ef  Catmumiet***,) 

By  the  Evacuating  dtnbu/ame  Co.  in 
Motor dmbu/ances-  assisted  by  ex- 
temporized transportation  as  may 
be  needed 


>N  HOSPITAL 


By  Motors,  Trains,  Boats.-no  regu- 
lar transportation-is  prescribed. 


HOSPITAL 


BEG1NMNG  OFDISfrfUBUTJNG  ZOME 

By  Hospital  Ships  and  Hospital  Trains. 


Intermediate  "ftest  /Stations"  may  be  established  at  any  point  a/otry  these 
"Lines  of  Aid'  where  the  distances  require  if. 

Fig.  1. — Colonel  Page's  diagram  (U.  S.  Army). 


mile,  to  the  "main  dressing  station"  a  mile  and  a 
half  more,  and  to  the  "casualty  clearing  station," 
say,  five  miles  further. 

At  the  first-aid  station,  and  possibly  at  the  dress- 


LOCATION  OF  BRITISH  HOSPITALS 


19 


ing  station,  only  urgent  operations  should  be  done, 
especially,  e.  </.,  for  the  arrest  of  hemorrhage.     No 


B      CL     t      t    CL   I     I     O 


negimenta.1    > 

Strefcher 

bearers 

Regimental  d 


Field 
ambulance 


Motor 

ambu/ance 

convoy 


/Ambulance 
train 


Con  vale  scent  depot^^ 


Fig.  2. — Colonel  Goodwin's  diagram  (British  Army). 

patient  should  ever  be  forwarded  from  there  with  a 
tourniquet  still  applied  on  a  limb.    In  his  admirable 


20  TREATMENT  OF  WAR  WOUNDS 

paper  on  "British  Surgery  at  the  Front"*  Bowlby 
advises  the  amputation  of  "completely  smashed 
limbs,"  and  the  retention  of  such  patients,  for  at  least 
a  day,  at  what  I  presume  will  correspond  to  our 
dressing  station  or  our  field  hospital.  Whether  this 
is  practicable  must  be  decided  by  the  responsible 
surgeon  in  each  case,  for  local  and  personal  condi- 
tions vary  too  much  for  a  hard  and  fast  rule. 

His  recommendation  that  abdominal  cases  and 
those  severe  cases  requiring  such  care  as  cannot  be 
given  at  this  first-aid  station  should  be  forwarded  to 
the  dressing  station  ("casualty  clearing  station"  of 
the  British)  at  once  by  special  motor  ambulances, 
and  not  be  kept  waiting  for  the  regular  motor  con- 
voys leaving  at  scheduled  time,  is  sound  both  from 
the  surgical  and  the  humanitarian  standpoint.  More- 
over, as  Bowlby  points  out,  had  sufficient  of  these 
motor  ambulances  been  in  use  in  the  early  months  of 
the  war,  they  would  have  saved  very  many  of  the 
wounded  from  being  taken  prisoners  by  the  Germans. 
'The  Motor  Ambulance,"  as  he  forcibly  and  rightly 
puts  it,  "  is  the  very  foundation  on  which  all  our  sur- 
gery at  the  front  is  based." 

This  whole  article  is  full  of  most  important  matter 
and  should  not  only  be  read,  but  be  studied,  by  every 
*  Brit.  Med.  Jour.,  June  2,  1917,  p.  705. 


AUTOMOBILES  ESSENTIAL  21 

military  surgeon.  I  find  it,  on  the  whole,  the  best 
summary  of  the  surgical  treatment  developed  by  the 
war  which  I  have  read.  I  shall  quote  liberally  from  it. 

The  automobile  is  indispensable.  The  American 
Field  Ambulance  in  France  alone  has  400  motor 
ambulances  in  service,  and  has  transported  300,000 
wounded. 

Dr.  Cabot  (p.  138)  calls  especial  attention  to  the 
value  of  interchangeable  standardized  stretchers.  In 
France  an  ambulance  leaves  the  patients  at  the  hos- 
pital lying  on  the  stretchers,  and  receives  exactly 
similar  empty  stretchers  with  their  regular  comple- 
ment of  blankets  in  exchange.  This  saves  time  and 
avoids  transferring  the  patients  to  hospital  stretch- 
ers, a  process  which  often  causes  severe  pain  and 
adds  to  existing  shock. 

Recently,  Dr.  Sigmund  L.  Gans,  of  Philadelphia, 
has  devised  a  framework,  made  chiefly  of  standard 
iron  pipe,  which  can  be  quickly  installed  on  any  kind 
of  touring  car  to  carry  two  patients  on  regulation 
stretchers,  while  five  or  six  sitting  and  one  partly 
lying  patient  (on  the  rear  seat)  can  also  be  carried  if 
necessary.  The  cost  of  this  attachment,  the  Packard 
Motor  Car  Company  inform  me,  for  a  touring  car, 
including  the  new  top,  is  $50.  For  cars  of  smaller 
size,  of  course,  the  cost  is  considerablv  less.  No  alter- 


Ml    3 

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24  TREATMENT  OF  WAR  WOUNDS 

ation  is  needed  in  the  car,  and  the  framework  can  be 
removed,  restoring  the  car  to  its  original  function  in 
a  very  short  time.  The  value  of  such  an  invention 
where  immense  numbers  of  wounded  must  be  quickly 


Fig.  5. — Light  railway  ambulance  trolley  (redrawn).  (Kindness  of  the 
editor  of  the  British  Medical  Journal  and  of  Sir  A.  A.  Bowlby,  Bart.  See 
Prefatory  Note.) 


moved  is  evident.  The  rapidity  of  the  spread  of 
infection  hour  by  hour  emphasizes  the  need  of  the 
quickest  possible  relief. 

In  what  may  be  called  the  permanent  trench  war- 
fare in  France  a  light  railway  ambulance  trolley  (Fig. 


TRANSPORTATION  BY  TROLLEY  25 

5),*  and  even  an  overhead  railway  ambulance  trol- 
ley (Fig.  6)*  in  the  trenches  for  the  rapid  transpor- 
tation of  the  wounded  have  been  developed.  These, 


Fig.  6. — Overhead  railway  ambulance  trolley  (redrawn).  (Kindness  of  the 
editor  of  the  British  Medical  Journal  and  of  Sir  A.  A.  Bowlby,  Bart.  See 
Prefatory  Note.) 


especially  the  overhead  trolley,  must  be  a  great  boon 
on  account  of  the  much  smoother  transportation. 

The  highly  organized  hospital  trains  in  France, 
over  30  of  which  are  now  in  operation  between  the 
evacuation  hospitals  (or  "evacuating  casualty  sta- 

*Brit.  Med.  Jour.,  June  2,  1917,  p.  711. 


26  TREATMENT  OF  WAR  WOUNDS 

tions,"  as  they  are  called  in  England)  and  the  base 
hospitals,  are  provided  with  permanent  staffs  of  sur- 
geons and  nurses,  with  traveling  laboratories,  #-ray 
rooms,  kitchens,  and  well-equipped  operating-rooms. 
In  France  hospital  barges  on  the  canals,  by  their 
smoothness  of  transit,  have  been  a  boon.  Well- 
equipped  hospital  ships,  especially  across  the  Chan- 
nel, have  taken  many  thousands  to  permanent  base 
hospitals  in  Great  Britain,  where  the  facilities  are 
equal  to  the  best. 

For  those  with  fractures,  especially  fractures  of 
the  thigh,  Blake's  splint  provides  excellent  fixation. 
Even  flesh  wounds,  especially  if  large  and  severe,  are 
greatly  benefited  by  such  fixation.  All  these  better 
means  of  speedy  and  more  comfortable  transporta- 
tion contribute  greatly  to  recovery.*  Cabot  and 
Gushing  emphasize  this  fact.  (See  their  letters,  pp. 
133,  144.) 

Chase  gives  a  useful  little  hint  as  to  plaster,  viz.: 
Just  before  the  cast  is  dry  it  may  be  coated  with  tal- 
cum powder  well  rubbed  in.  This  makes  a  smooth 
surface,  which  can  be  washed,  and  on  it  the  date  and 
other  memoranda  may  be  written. 

*  Lord  Northcliffe's  interesting  account  of  a  "Visit  to  the 
Front"  is  reprinted  from  the  London  Times  of  October  4,  1916, 
in  the  Military  Surgeon  for  December,  1916. 


The  "Balkan  splint"  is  simple,  useful,  and  widely 
employed  in  hospitals,  but  it  is  not  adapted  for  trans- 
portation. The  Thomas  and  other  similar  splints 
have  been  much  used  by  the  British. 

Crile  insists  rightly  upon  the  value  of  morphin  for 


c 

Fig.  7. — Blake's  splint:  A,  The  frame.  B,  Shows  the  padded  strap  and 
buckle  to  encircle  the  thigh.  C,  Details  of  the  foot-piece.  On  this  the  slits  for 
the  buckles  should  be  105  to  110  mm.  apart.  (Courtesy  of  Dr.  Joseph  A. 
Blake.) 

men  suffering  severely,  whether  in  hospitals  or  during 
transportation.  After  the  second  Bull  Run,  when 
a  train  of  over  100  ambulances  carrying  the  wounded 
to  Washington,  after  they  had  been  lying  for  three 
days  uncared  for  and  undressed,  halted  in  the  night 
at  Centreville,  I  found  the  two  most  needed  things 


88  TREATMENT  OF  WAR  WOUNDS 

were  water  and  morphin.  On  the  other  hand,  too 
much  morphin  is  as  bad  as  too  little,  especially  in 
abdominal  cases. 

3.    New   weapons   have   caused    a    new  type    of 
wounds.     At  first  there   were  many  bullet  wounds, 


Fig.  8. — Balkan  splint  as  used  at  the  American  Ambulance,  Neuilly-sur- 
Seine,  Paris,  France.  (Crile,  in  Annals  of  Surgery,  July,  1915.  Attributed  to 
Lt.  Col.  Miles  by  Sir  Geo.  H.  Makins,  Brit.  Med.  Jour.,  June  16, 1917.) 

then  shrapnel  wounds  outnumbered  those  caused  by 
the  rifle,  and  now  the  high  explosive  shell  is  the  chief 
weapon.  Artillery  has  leaped  into  new  and  dominat- 
ing importance.  These  shells,  all  surgeons  agree,  pro- 
duce terrible  and  wide-spread  mutilations.  Frag- 


WIDE-SPREAD  DAMAGE  BY  SHELLS  29 

ments  of  the  shells  not  only  may  lodge,  but  also  in 
most  cases  carry  deep  into  the  tissues,  in  the  majority 
of  wounds,  bits  of  dirty  clothing,  skin,  and  other 
foreign  bodies,  all  heavily  infected.  Diligent  search 
must  be  made  for  such  foci  of  infection  at  the  very 
first  opportunity  for  a  thorough  dressing,  or  deep 
and  wide-spread  infection  is  sure  to  follow. 

It  must  not  be  forgotten  that  these  modern  bullets 
and  fragments  of  high  explosive  shells  produce  grave 
destruction  of  tissue  not  merely  in  the  track  of  the 
missile,  but  that  the  tissues  at  varying  distances  all 
around  and  beyond  the  wounds  are  devitalized.  This 
destruction  is  often  not  recognizable  by  the  eye  or 
touch  until  some  time  has  passed.  Bowlby,  quoted  by 
Moynihan,*  has  shown  that  a  kidney  wounded  in  its 
lower  pole  presented  to  the  naked  eye  a  normal  ap- 
pearance at  its  upper  end,  but  the  microscope  showed 
that  the  tubules  in  that  part  were  disorganized. 

This  wide-spread  devitalizing  of  the  tissues  has  led 
to  the  common-sense  practice,  especially  urged  by 
Carrel,  after  primary  disinfection,  of  excision  of  the 
tissues  surrounding  the  wound  itself  instead  of  allow- 
ing them  to  slough  off  and  serve  as  an  excellent  nidus 
for  infection.  Shells  and  shrapnel  also  frequently 
cause  multiple  wounds.  The  fragments  of  a  shattered 
*  Brit.  Med.  Jour.,  March  4,  1916. 


30  TREATMENT  OF  WAR  WOUNDS 

bone  act  as  additional  secondary  projectiles  and  fur- 
ther enlarge  the  area  of  destruction. 

Chase*  says  that  "multiple  wounds  are  the  rule. 
.  .  .  Thirty,  forty,  or  fifty  wounds  from  the  ex- 
plosion of  a  shell  close  by  are  not  particularly  rare." 
He  then  describes  one  stretcher-bearer  who  had  "well 
over  one  hundred  wounds.  We  picked  out  pieces  of 
shell,  newspaper,  clothing,  and  gravel  for  days  after- 
ward." Fortunately,  no  one  of  the  wounds  was  seri- 
ous, and  in  the  course  of  a  month  he  was  ready  for 
furlough. 

All  these  complicating  conditions  complicate  also 
the  treatment.  But  the  chief  outstanding  fact  is 
virulent  and  all-pervading  infection. 

The  soil  of  Belgium  and  France  has  been  cultivated 
for  over  twenty  centuries,  since  even  before  the  days 
of  Caesar's  Gallic  War.  The  fields  have  been  roamed 
over  by  cattle,  horses,  swine,  and  other  animals,  in- 
cluding man  himself;  the  soil  has  been  manured 
thousands  of  times,  and  so  is  deeply  and  thoroughly 
impregnated  with  fecal  bacteria  in  addition  to  the 
ordinary  pyogenic  bacteria. 

The  soldiers  have  lived  in  trenches  for  months, 
begrimed  and  bedaubed  with  mud,  without  suitable 
facilities  for  bathing  and  change  of  under  and  outer 
*  Annals  of  Surgery,  July,  1917. 


BACTERIOLOGY  OF  WOUNDS  31 

clothing,  especially  in  the  early  days  of  the  war.  It 
was  not  uncommon  at  that  period  for  a  man  to  be 
unable  to  change  even  his  trousers  for  weeks.  When, 
therefore,  a  missile  carried  into  the  wound  a  piece  of 
dirty,  mud-impregnated  skin,  coat,  trousers,  under- 
clothing or  socks,  or  when  a  large  lacerated  wound 
was  in  contact  with  the  long-soiled  clothing,  and  the 
wounded  man  would  perhaps  lie  on  the  ground  un- 
cared  for  for  hours  or  days,  it  was  no  wonder  that 
violent  infection  from  pyogenic  organisms  and  the 
bacteria  of  tetanus  and  gas  gangrene  ran  riot. 

Carrel*  has  observed  that  when  a  wound  was  ex- 
amined bacteriologically  as  early  as  six  hours  after  it 
had  been  inflicted  there  was  found  a  varied  flora  of 
both  aerobic  and  anaerobic  bacteria,  but  that  they 
were  few  in  number,  and  localized  chiefly  around  the 
missile  or  a  bit  of  clothing,  etc.,  without  as  yet  spread- 
ing far  and  wide  into  the  tissues.  Twenty-four  hours 
later,  however,  the  bacteria  were  found  everywhere, 
and  were  too  numerous  to  count.  Moreover,  as 
Wright  has  pointed  out,  when  there  has  been  delay  in 
dressing  a  wound,  the  dried  blood  sealing  the  wound 
creates  an  almost  ideal  condition  for  the  growth  of 
the  deadly  anaerobic  bacteria  of  tetanus  and  gas 

*Bull.  Acad.  Med.,  Ixxiv,  No.  40,  and  Brit.  Med.  Jour., 
Oct.  23,  1915. 


32  TREATMENT  OF  WAR  WOUNDS 

gangrene.  (Vide  infra,  Tissier's  observation,  p.  90.) 
It  is  no  wonder  then  that  experience  has  shown  that 
excision  of  this  damaged  and  heavily  infected  tissue 
is  one  of  the  prime  factors  in  the  treatment  of  the 
badly  wounded. 

Bowlby  (loc.  cit.}  points  out  that  "if  a  badly 
wounded  man  cannot  be  rescued  and  brought  into 
the  field  ambulance  until  after  the  lapse  of  twenty- 
four  or  thirty -six  hours,  the  wound  is  often  already 
so  badly  infected  and  the  patient  himself  is  in  so  toxic 
a  state  that  surgical  treatment  has  but  little  chance. 
It  may  be  said  truly  that  the  most  important  altera- 
tion in  treatment  since  the  early  days  of  the  war  is 
that  excision  of  damaged  tissue  has  become  the  rou- 
tine method,  and  that  the  earlier  it  is  carried  out,  the 
more  likely  it  is  to  be  successful." 

Could  there  possibly  be  stronger  reasons  for  urging 
that  every  wounded  man,  if  it  is  at  all  possible,  should 
obtain  thorough  care  during  the  very  first  golden 
hours,  when  efficient  treatment  would  save  his  life? 
Military  conditions  may,  and  too  often  do  prevent 
this  early  dressing,  but  this,  above  all  other  factors 
for  recovery,  should  be  the  aim  both  of  the  surgeon 
and  the  commander,  for  so  human  lives  are  saved  and 
armies  are  less  depleted  by  death  and  disability. 

In  the  navy,  on  the  contrary,  where  the  factor  of 


EXHAUSTION  OF  SOLDIERS  33 

infected  soil  was  not  present,  "sailors  with  the  most 
severe  type  of  wounds,  ragged,  irregular,  with  uneven 
surface,  produced  by  herniated  muscles  and  re- 
tracted, severed  fibers,  usually  recovered  quickly."* 

Moreover,  in  the  terrible  but  magnificent  retreat 
from  the  Aisne  to  the  Marne,  many  and  in  some 
cases  almost  every  man  was  exhausted  to  the  last 
degree  mentally  as  well  as  physically.  Crilef  has 
given  a  wonderful  picture  of  the  exhaustion  of  these 
patients,  who  practically  slept  while  they  marched, 
who  slept  through  painful  dressings  or  even  operations. 
The  nervous  strain  to  which  the  men  are  subjected 
in  the  trenches  impairs  greatly  their  ability  to  with- 
stand the  almost  malignant  infection  which  invades 
the  great  gaping  wounds. 

Early  experiences  in  the  war  demonstrated  the  fact 
that  both  antisepsis  and  asepsis  as  heretofore  prac- 
tised had  been  vanquished  by  Mars.  Each  was  tried 
and  each  failed.  It  was  even  proclaimed  that  Lister's 
work  went  for  naught.  Now,  however,  antisepsis  and 
asepsis  (in  its  proper  place)  have  come  into  their  own 
again,  and  Lister  is  still  the  apostle  of  good  tidings. 
The  reasons  are  plain.  First,  we  did  not  then  pos- 
sess sufficiently  effective  antiseptics,  such  as  modern 

*  Jour.  Amer.  Med.  Assoc.,  May  22,  1915,  p.  1765. 
t  Mechanistic  View  of  War  and  Peace,  Macmillan,  1916. 
3 


34  TREATMENT  OF  WAR  WOUNDS 

research  has  now  given  us;  second,  we  were  not  mas- 
ters of  an  effective  and  successful  technic.  We  owe 
these  especially  to  two  men — Dakin  and  Carrel — who 
have  wrought  a  marvelous  revolution. 

Lister  taught  us,  above  all,  how  to  prevent  infec- 
tion; Dakin  and  Carrel,  following  Lister's  principles, 
have  taught  us  how  to  conquer  even  rampant  infec- 
tion. For  nearly  half  a  century  surgeons  have  been 
fighting  firmly  entrenched  infection,  but  always  in 
vain.  It  required  the  stern  stimulus  of  war  to  enable 
us  to  win  the  victory.  Prevention  and  cure  both  are 
now  ours. 

Two  still  newer  antiseptics  with  apparently  quite 
remarkable  bactericidal  qualities  have  been  recently 
discovered — too  recently,  I  think,  as  yet  for  them  to 
have  had  the  test  of  a  large  experience,  as  they  ought 
surely  both  to  have. 

The  first  is  designated  by  the  short  name  "flavine" 
instead  of  the  long  chemical  name.  A  full  account 
of  this,  with  the  process  of  manufacture,  is  given  by 
Browning  and  his  colleagues  fom  the  Bland-Sutton 
Institute  of  Pathology  of  the  Middlesex  Hospital, 
London,  in  the  British  Medical  Journal  for  January 
20,  1917,  p.  73. 

For  technical  reasons  "flavine,"  as  one  of  the 
"acridin"  series,  is  now  called  " acriflavine."  A  still 


RECENT  NEW  ANTISEPTICS  35 

more  potent  preparation  is  foreshadowed  and  is  to  be 
called  "proflavine.  "* 

Dakin,  in  the  same  journal  for  June  23d,  indorses 
Browning's  statements  as  to  acriflavine.  Its  anti- 
septic action,  instead  of  being  diminished  by  blood- 
serum,  is  increased  even  up  to  five  times  its  potency 
in  water.  Moreover,  as  Browning  showed,  it  is  harm- 
less to  the  tissues  and  even  to  the  activity  of  the 
leukocytes  (phagocytosis) . 

The  second  one,  which  is  still  more  recent,  is  an- 
nounced in  an  important  paper  by  Schamberg,  Kol- 
mer,  and  Raiziss,  on  a  "Mercurial  Germicide,"  which 
they  have  named  "  Mercurophen, "  in  the  Journal  of 
the  American  Medical  Association  for  May  19,  1917, 
p.  1458. 

Mercurophen  apparently  does  not  corrode  metal 
instruments.  It  is  said  to  be  non-irritating,  yet  to 
be  a  far  more  powerful  germicide  than  corrosive  sub- 
limate, carbolic  acid,  etc.,  and  therefore  excellent 
for  sterilizing  the  hands.  Though  so  effective  a 
germicide,  it  is  non-poisonous.  Dr.  Walter  J..  Free- 
man has  used  it  for  some  time  in  his  laryngologic 
work  as  freely  as  he  would  a  boric-acid  solution  and 
commends  it  highly.  Several  of  my  surgical  and 
ophthalmologic  friends  are  well  satisfied  with  the 
*  Brit.  Med.  Jour.,  June  9,  1917. 


36  TREATMENT  OF  WAR  WOUNDS 

clinical  results,  in  the  moderate  number  of  cases  in 
which  they  have  been  able  to  try  it,  in  the  short 
time  since  it  has  been  available.  That  it  has  been 
used  as  a  preoperative  disinfectant  for  the  eye,  and 
that  sutures  have  been  left  in  place  for  three  or  four 
weeks  without  causing  any  irritation,  speak  well  for 
its  not  being  harmful  to  the  delicate  cells  of  the  cornea 
and  conjunctiva,  nor  to  the  tissue  cells  of  a  wound. 

Several  new  methods  of  treating  infection  have 
been  proposed.  Each  has  had  its  warm  advocates, 
and  each  has  been  assaulted  sometimes  with  more  or 
less  acerbity.  A  number  of  these  are  referred  to  in 
an  admirable  series  of  articles  on  Surgery  in  the 
British  Navy,*  together  with  an  assessment  of  their 
relative  values. 

Personally,  I  have  seen  none  of  them  used.  I  can 
judge  only  by  the  published  results.  "By  their  fruits 
ye  shall  know  them."  Judging  by  this  standard,  I 
can  only  conclude  that  one  method — that  of  Carrel 
and  Dakin — has  shown  results  so  much  superior  to 
the  others  that  I  shall  restrict  myself  to  this  method 
alone  in  detail.  If  I  am  asked  to  give  the  reason,  I 
need  only  quote  the  following  paragraph,  describing 
what  Dr.  C.  L.  Gibson,  of  New  York,f  saw  at  La 

*  Brit.  Med.  Jour.,  April  28,  1917,  p.  533. 
f  General    Bulletin,    Society   of   the   New   York   Hospital, 
March  27,  1917. 


COMPOUND  FRACTURES  AND  NO  PUS          37 

Panne,  Belgium,  where  the  method  is  strictly  and 
efficiently  carried  out. 

"Dr.  Depage  greeted  me  by  saying  that  he  had  80 
compound  fractures  all  grouped  in  one  ward  and  that 
not  one  was  suppurating.  He  kindly  devoted  a  whole 
forenoon  to  their  demonstration,  and  I  had  an  oppor- 
tunity to  see  every  one  of  these  80  cases,  even  to  the 
smallest  details.  None  of  the  dressings  were  touched 
till  I  had  an  opportunity  to  see  them  and  estimate  the 
amount  and  nature  of  the  discharge  contained  on 
them.  I  had  an  opportunity  also  to  see  the  bacterial 
chart  of  every  one  of  these  cases,  see  a  number  of 
these  cases  'closed,'  and  in  some  cases  observe  their 
condition  and  final  healing.  I  was  able  not  only  to 
corroborate  Dr.  Depage's  statement  that  not  one  of 
these  compound  fractures  was  suppurating,  but  could 
affirm,  in  addition,  that  I  failed  to  see  a  single  drop 
of  pus,  in  any  one  of  these  cases.  When  one  remem- 
bers that  these  wounds  offer  the  maximum  possibili- 
ties, particularly  the  shell  wounds,  with  terrific  man- 
gling of  the  tissues,  extensive  splintering  of  bone,  har- 
boring many  and  diverse  forms  of  projectiles  and 
foreign  bodies,  necessarily  all  primarily  infected, — in 
other  words,  the  worst  possible  imaginable  wounds,— 
the  result  is  something  one  must  know  for  oneself  to 
appreciate. 

"These  wounds  heal  in  a  manner  that  is  simply  in- 
describable. One  has  to  see  the  behavior  of  these  su- 
tured wounds  oneself  to  realize  what  happens.  They 


.'J5JJ794 


38  TREATMENT  OF  WAR  WOUNDS 

heal  with  no  more  reaction  from  their  appearance  and 
manifestations  than  would  be  given  by  a  wound  which 
has  been  sutured  on  a  cadaver — total  absence  of  re- 
action, pain,  swelling,  redness,  and  even  of  infiltration 
around  the  wound  edges.  Dr.  Dehelly,  of  Havre,  tells 
me  that  he  has  closed  400  of  these  wounds  with  only 
six  failures  to  obtain  perfect  primary  union.  Of  these 
six  mishaps,  none  was  of  any  importance,  and  in  some 
of  these  Dehelly  said  the  fault  was  probably  due  to 
his  failure  to  await  complete  sterilization,  as  evi- 
denced by  the  bacterial  count." 

I  have  never  yet  seen  any  report  of  80  cases  of  com- 
pound fracture  of  the  thigh  without  a  drop  of  pus 
when  treated  by  any  other  method.  When  myself  in 
active  practice,  I  should  have  been  more  than  grati- 
fied had  I  realized  such  a  result,  even  in  the  best  of 
conditions  and  in  civil  life,  where  infection  is  far  more 
easily  dealt  with. 

Tuffier  alleges  that  80  per  cent,  of  all  amputations 
are  due  to  infection.  If  we  can  now  conquer  infection, 
most  of  these  mutilations  will  probably  be  avoided. 

What  an  immense  boon  this  will  be  to  the  soldiers, 
and  therefore  to  the  community,  by  enabling  them, 
even  if  only  partly,  to  earn  their  daily  bread,  is  most 
evident.  The  military  commanders  will  be  equally 
gratified  by  the  return  to  their  commands  of  many 
of  the  wounded  who  otherwise  would  have  been 


EUSOL  AND  EUPAD  39 

returned  to  civil  life  in  this  mutilated  condition  or 
have  been  carried  to  the  cemetery. 

It  is  but  fair  to  state  that  independently  in  the 
British  Medical  Journal,  July  24, 1915,  p.  129,  Lorrain 
Smith,  Drennan,  Rettie,  and  Campbell,  of  the  De- 
partment of  Pathology  in  the  University  of  Edin- 
burgh, published  their  "Experimental  Observations 
on  the  Antiseptic  Action  of  Hypochlorous  Acid  and 
its  Application  to  Wound  Treatment."  They  devised 
two  forms  of  its  use — a  powder  which  they  named 
Eupad,  and  a  solution  which  they  named  Eusol. 
Eupad  consisted  of  equal  weights  of  finely  ground 
bleaching  powder  (chlorid  of  lime)  and  of  boric  acid. 
Eusol  was  standardized  at  0.5  per  cent,  of  hypo- 
chlorous  acid.  Both  of  these  preparations  have  been 
much  used  with  good  results,  but,  on  the  whole, 
they  do  not  seem  to  have  been  so  satisfactory  or  at 
least  have  not  gained  the  same  wide-spread  repute 
as  Dakin's  fluid. 

Hypochlorous  solution  has  been  produced  from 
hypertonic  saline  by  Beattie,  Lewis,  and  Gee,*  and 
is  claimed  by  them  to  have  certain  advantages  over 
other  similar  preparations. 

*  Brit.  Med.  Jour.,  February  24,  1917,  p.  256. 


THE  DAKIN-CARREL  METHOD 

The  Dakin-Carrel  method  consists  in  the  use  of 
Dakin's  fluid  of  sodium  hypochlorite  in  a  solution  of 
0.5  per  cent,  strength,  with  a  special  technic  devised 
by  Carrel.  The  method  requires  special  training.  To 
provide  this  training  the  Rockefeller  Foundation  is 
now  erecting  a  special  temporary  hospital  on  the 
grounds  of  the  Rockefeller  Institute  in  New  York,  and 
will  have  the  personal  services  of  Dakin  and  Carrel 
for  the  instruction  of  surgeons  in  the  military  service 
of  the  country.  Much  of  the  adverse  criticism  has 
seemed  to  come  from  those  who  have  not  had  the 
advantage  of  instruction  by  Carrel  at  Compiegne  or 
by  Depage  at  La  Panne.  Depage  personally  visited 
Compiegne  and  there  became  familiar  with  the  details 
of  the  method.  Those  who  have  visited  Carrel's  and 
Depage's  hospitals  have  come  away  enthusiastic  in 
praise  of  the  results  there  attained.  The  results,  they 
aver,  are  simply  wonderful. 

Dakin's  Fluid. — While  in  this  country,  Dr.  Dakin 
has  been  kind  enough  to  give  me  the  following  for- 
mulas of  the  fluid — one  with  and  the  other  without 

40 


THE  DAKIN-CARREL  METHOD  41 

boric  acid.    The  latter  seems  to  have  given  the  best 
results  in  the  hands  of  those  who  have  tested  both. 

Preparation  of  the  Dakin  Solutions. — "Neutral 
hypochlorite  prepared  with  boric  acid  is  best  made  as 
follows :  One  hundred  and  forty  grams  of  dry  sodium 
carbonate  (NaCO),  or  400  grams  of  the  crystallized 
salt  (washing  soda),  are  dissolved  in  12  liters  of  tap- 
water,  and  200  grams  of  chlorid  of  lime  (chlorinated 
lime)  of  good  quality  are  added.  The  mixture  is  well 
shaken,  and,  after  half  an  hour,  the  clear  liquid  is 
siphoned  off  from  the  precipitate  of  calcium  carbonate 
and  filtered  through  a  plug  of  cotton;  40  grams  of 
boric  acid  are  added  to  the  clear  filtrate,  and  the  re- 
sulting solution  is  ready  for  use.  A  slight  additional 
precipitate  of  calcium  salts  may  slowly  occur,  but  it 
is  of  no  significance.  The  solution  should  not  be  kept 
longer  than  one  week.  The  boric  acid  must  not  be 
added  to  the  mixture  before  filtering,  but  afterward. 
The  solution  should  be  tested  for  neutrality  by  adding 
some  of  it  to  a  pinch  of  solid  phenolphthalein.  If  a 
red  color,  indicating  free  alkali,  should  develop,  a 
little  more  boric  acid  must  be  added  in  order  to  re- 
move it." 

Daufresne's  Technic.—  "Neutral  hypochlorite  pre- 
pared without  boric  acid  is  best  made  according  to 
the  formula  given  by  Daufresne,  and  at  the  present 
time  is  perhaps  more  generally  used  than  any  of  the 
other  modifications. 

"Two  hundred  grams  of  good  bleaching  powder  are 


42  TREATMENT  OF  WAR  WOUNDS 

put  in  a  12-liter  bottle  with  five  liters  of  tap-water. 
The  solution  is  shaken  vigorously  and  allowed  to 
stand  for  at  least  six  hours,  unless  a  mechanical  shaker 
is  used,  when  half  an  hour's  shaking  will  be  found 
sufficient.  In  another  vessel  100  grams  of  dry  sodium 
carbonate  and  80  grams  of  sodium  bicarbonate  are 
dissolved  in  five  liters  of  cold  water  and  then  added  to 
the  bleaching  powder  mixture.  The  whole  is  shaken 
vigorously  for  a  few  minutes,  and  the  precipitate  al- 
lowed to  settle.  At  the  end  of  half  an  hour  the  clear 
solution  is  siphoned  out  and  then  filtered  through 
paper.  The  proportions  given  above  for  the  carbo- 
nate and  bicarbonate  of  soda  are  those  given  by  Dau- 
fresne.  It  is  our  experience,  however,  that  with  most 
brands  of  American  bleaching  powder  it  is  better  to 
use  90  grams  of  each  salt.  This  solution  must  invaria- 
bly be  tested  for  neutrality  by  adding  a  pinch  of  solid 
phenolphthalein  to  a  little  of  the  solution.  If  the  solu- 
tion should  react  alkaline,  one  of  three  methods  must 
be  employed  to  correct  it,  otherwise  skin  irritation  will 
surely  result. 

"  (a)  Pass  carbon  dioxid  gas  into  the  solution  until 
a  sample  shows  no  alkalinity  when  tested  as  described. 
This  is  perhaps  the  best  method. 

"  (6)  A  neutral  hypochlorite  may  be  secured  by 
reducing  the  proportion  of  carbonate  of  soda  and  in- 
creasing the  bicarbonate. 

"(c)  Boric  acid  may  be  added  until  neutrality  is 
secured. 

"An  advantage  of  the  carbonate-bicarbonate  prepa- 


THE  DAKIN-CARREL  METHOD  43 

ration  is  that  it  possesses  greater  stability  and  can  be 
kept  for  several  weeks  without  much"  deterioration. 
On  the  other  hand,  with  varying  qualities  of  bleach- 
ing powder,  containing  different  amounts  of  free  lime, 
it  is  more  difficult  to  adjust  the  proportions  so  as  to 
obtain  a  neutral  solution  directly.  Probably  those 
having  adequate  laboratory  facilities  wTill  prefer  the 
carbonate-bicarbonate  solution,  while  the  mixture 
containing  boric  acid  is  readily  made  under  less  favor- 
able circumstances." 

In  addition  to  this  I  add  some  further  details  from 
Dr.  H.  H.  M.  Lyle's  excellent  paper.* 

The  fluid  is  "an  ideal  isotonic  wound  antiseptic  of 
high  bacterial  and  low  toxic  or  irritating  quality,"  in 
which  it  differs  from  the  old  familiar  Labarraque's 
solution.  It  does  not  injure  the  living  tissues. 

Lyle  adds  the  following  note  as  to  Daufresne's 
technic:  'The  solution  of  sodium  hypochlorite  for 
surgical  use  must  be  free  from  caustic  alkali;  it  must 
contain  only  from  0.45  to  0.50  per  cent,  of  hypo- 
chlorite. Under  0.45  per  cent,  it  is  not  active  enough, 
and  above  0.5  per  cent,  it  is  irritant."  At  50  per  cent, 
the  skin  around  the  wound  must  be  protected  by  yel- 
low (not  white)  vaselin. 

"  Test  for  Alkalinity. — As  the  commercial  chlorin- 
-*  Jour.  Amer.  Med.  Assoc.,  January  13,  1917. 


44  TREATMENT  OF  WAR  WOUNDS 

ated  limes  are  of  inconstant  strength,  the  solution 
should  always  be  tested.  Pour  20  c.c.  of  the  solution 
into  a  glass,  and  drop  on  the  surface  of  the  liquid  a  few 
centigrams  of  powdered  phenolphthalein.  Agitate  the 
fluid  by  giving  the  glass  a  circular  motion,  as  if  one 
were  rinsing  the  glass.  The  liquid  ought  to  remain 
colorless.  A  red  tint  more  or  less  intense  indicates  the 
presence  of  a  quantity  of  free  alkali  or  an  incomplete 
carbonation  due  to  faults  in  the  technic. 

"  Titration  of  the  Solution. — Measure  10  c.c.  of  the 
solution;  add  20  c.c.  of  1:  10  iodin  solution  and  20 
c.c.  of  acetic  acid.  Pour  into  this  mixture  a  decinor- 
mal  solution  (2.48  per  cent.)  of  sodium  thiosulphate 
(hyposulphite)  until  decoloration. 

"Let  N  equal  the  number  of  cubic  centimeters  of 
thiosulphate  employed.  Then  the  quantity  of  sodium 
hypochlorite  for  100  c.c.  of  the  solution  would  be 
given  by  the  equation: 

T  =  X  X  0.03725. 

"  Precautions:  Never  heat  the  solution!  If,  in  case  of 
an  emergency,  it  is  necessary  to  titrate  the  chlorinated 
lime,  use  only  water,  never  with  the  solution  of  soda 
salts. 

"  Titration  of  Chlorinated  Lime  (Bleaching  Powder). 
-The  variation  in  the  strength  of  the  commercial 
products  makes  it  necessary  to  determine  the  amount 
of  active  chlorin  in  the  bleaching  powder.  The  first 
step  is  to  obtain  an  average  sample.  This  is  done  by 
selecting  small  amounts  of  the  bleaching  powder  from 


THE  DAKIN-CARREL  METHOD 


45 


"QUANTITIES  OF  INGREDIENTS  REQUIRED  TO  OBTAIN  10  LI- 
TERS OF  0.5  PER  CENT.  HYPOCHLORITE  SOLUTION 


INGREDIENTS 

LIME  (Cl) 

Chlorinated 
Lime 

Sodium 
Carbonate 

Sodium 
Bicarbonate 

Per  Cent. 
20                                   .... 

Gm. 
250 

Gm. 
125 

Gm. 
100 

21        .                  

240 

120 

96 

22  

230 

115 

93 

23  

220 

110 

88 

24  

210 

105 

84 

25 

200 

100 

80 

26 

190 

95 

76 

27 

180 

90 

72 

28  ...                         .... 

175 

87 

70 

29  

170 

85 

68 

30  

165 

82 

66 

31 

160 

80 

65 

32 

155 

78 

62 

33  

151 

75 

60 

34  

147 

73 

59 

35  

143 

71 

57 

different  parts  of  the  jar.  Weigh  20  gm.  of  the 
selected  powder  and  mix  it  with  one  liter  of  water. 
Allow  it  to  remain  in  contact  for  a  few  hours;  then 
take  10  c.c.  of  the  clear  fluid,  add  to  it  20  c.c.  of  a  10 
per  cent,  solution  of  potassium  iodid  and  2  c.c.  of 
acetic  or  hydrochloric  acid.  To  the  resultant  solution 
add  a  decinormal  solution  of  sodium  thiosulphate 
(2.48  per  cent.)  until  decoloration.  The  number  N 
of  cubic  centimeters  of  thiosulphate  employed,  mul- 
tiplied by  1.775,  will  give  the  weight  N  of  active 


46 


TREATMENT  OF  WAR  WOUNDS 


Fig.  9. — Carrel's  irrigation  ap- 
paratus: a,  Reservoir  for  Dakin's 
fluid;  b,  the  main  distributing 
tube;  c,  the  metal  pinch-cock;  d, 
glass  tube  with  multiple  openings; 
e,  e,  e,  e,  final  distributing  tubes 
closed  at  distal  end,  but  perforated 
with  openings  of  1  mm.  each  (Car- 
rel and  Dehelly). 


chlorin  contained  in  100  gm. 
of  chlorinated  lime.  The 
test  is  applied  to  every  new 
sample  of  bleaching  powder. 
If  the  sample  contains  more 
than  25  per  cent,  of  active 
chlorin,  the  proportion  of 
the  three  chemicals  in  the 
formula  must  be  decreased; 
and  if  it  is  less  than  25  per 
cent.,  it  must  be  increased. 
That  is,  each  of  the  three 
numbers— 200,  100,  and  80 
—are  multiplied  by  25 /N, 
N  representing  the  weight  of 
the  active  chlorin  per  cent, 
of  the  bleaching  powder. 

"Necessary    Materials.— 
1.    A    solution   of    0.5    per 
cent,    sodium   hypochlorite 
prepared  by  the  Dakin  and 
Daufresne  technic. 

"2.  A  glass  container  with 
a  capacity  of  from  500  to 
1000  c.c.  (Fig.  9,  a). 

"3.  Two  yards  of  moder- 
ate-sized rubber  tubing. 

"4.  An  adjustable  clamp 
for  controlling  the  flow  of 
the  solution  (Fig.  9,  c). 


THE  DAKIN-CARREL  METHOD 


47 


"5.  Rubber  instillation  tubes  about  25  cm.  long, 
with  assorted  diameters  (average  size,  No.  16  French). 
These  tubes  are  tied  at  the  extremity  and  perforated 


Fig.  10. — Showing  Carrel's  glass  tube  (Fig.  9,  d)  to  connect  the  main  distrib- 
uting tube  (Fig.  9,  b)  from  the  reservoir  to  multiple  final  small  distributing 
tubes  (Carrel  and  Dehelly). 


Fig.  11. — Showing  the  mode  in  which  the  small  distributing  tubes  are  carried 
through  the  dressing  to  the  various  parts  of  the  wound  (Carrel  and  Dehelly). 

with  holes  made  with  a  punch.  The  primary  and 
secondary  tubes  are  7  mm.  in  internal  diameter,  the 
final  distributing  tubes  4  mm.,  and  the  little  holes  in 
these  tubes  are  only  1  mm.  (^V  inch)  in  diameter. 


48  TREATMENT  OF  WAR  WOUNDS 

"6.  Ordinary  rubber  tube  drains,  from  25  to  35 
cm.  long,  without  lateral  holes. 

"7.  Glass  connecting  and  distributing  tubes  (Fig. 
12). 

"8.  The  dressings  consist  of  cotton  surrounded  by 
gauze.  The  cotton  consists  of  a  layer  of  absorbent 
cotton  with  a  thicker  layer  of  non-absorbent  cotton. 
These  dressings  are  about  3  cm.  thick,  and  of  different 
sizes.  Three  different  sizes  are  sufficient — one  large 
enough  to  surround  the  leg  once,  a  second  to  surround 


Fig.  12. — Showing  a  similar  distribution  as  in  Fig.  11,  by  means  of  a  Y-tube,  thus 
doubling  the  number  of  final  distributing  tubes  (Carrel  and  Dehelly) . 


the  arm,  the  third  still  smaller.  Webbing  straps  with 
buckles  to  fasten  the  dressing  in  place. 

"9.  Sterilized  pieces  of  gauze  impregnated  with 
yellow  petrolatum  to  be  used  in  the  protection  of  the 
skin. 

"  Operative  Technic  to  Prepare  the  Wound  for  the 
Introduction  of  the  Antiseptic. — The  future  course  of 
the  wound  is  directly  dependent  on  the  thoroughness 
of  the  first  surgical  act.  This  should  be  carried  out 
under  the  strictest  aseptic  precaution  and  at  the  ear- 
liest possible  moment.  It  consists  of  a  thorough, 


THE  DAKIN-CARREL  METHOD 


49 


methodical,  mechanical  disinfection  of  the  wound, 
with  the  extraction  of  all  shell  fragments,  particles  of 
clothing,  dirt,  etc.  [For  the  new  stereo-fluoroscopic 
method  of  extracting  foreign  bodies, 
see  p.  68.] 

"The  operative  field  is  painted  with 
tincture  of  iodin,  and  the  bruised  and 
necrotic  skin-edges  of  the  wound  are 
trimmed  away  with  a  sharp  knife.  The 
knife  and  forceps  are  then  put  aside. 
With  new  instruments  the  wound  is 
laid  open  like  a  book  and  gently  ex- 
plored for  shell  fragments,  pieces  of 
clothing,  pockets,  etc.  Everything 
that  could  have  been  infected  by  the 
traumatism  or  could  become  the  source  „„„, , ,  ,_ 

rJ 


Fig.  13. — Showing  Carrel  method  of  irrigating  wound  with  the  Dakin  fluid. 
Note  on  the  main  distributing  tube  the  pinch-cock  below  the  reservoir.  The 
wound  is  covered  with  the  dressing,  which  is  fastened  by  safety-pins.  The  dis- 
tributing tube  is  similarly  held  in  place  by  being  pinned  to  the  plaster  cast 
(Carrel  and  Dehelly  modified). 


50  TREATMENT  OF  WAR  WOUNDS 

of  infection  is  removed.  All  non-infected  tissues  and 
tissues  unlikely  to  become  infected  are  preserved. 

''Gentleness  of  manipulation  is  the  keystone  of  the 
technic.  Brutalization  of  the  traumatized  tissue  is  a 
technical  crime.  In  many  of  the  cases  it  will  be  found 
that  fibers  of  clothing,  dirt,  grass,  etc.,  are  encrusted 
in  the  muscular  surfaces  of  the  wounds.  To  avoid 
overlooking  this  blood-stained  debris  the  track  of  the 
projectile  must  be  lightly  but  methodically  resected. 
Great  conservatism  is  exercised  in  the  removal  of  com- 
minuted fragments  of  bone.  The  same  minute  and 
careful  mechanical  cleansing  is  carried  out  in  osseous 
wounds  as  in  the  soft  parts.  Before  placing  the  in- 
stillation tubes,  a  careful  revision  of  the  wound  is 
made,  and  particular  attention  paid  to  securing  a 
perfect  hemostasis.  Muscular  tissue  infiltrated  with 
blood  is  difficult  to  disinfect. 

''There  is  another  reason  special  to  the  employment 
of  Dakin's  solution  which  calls  for  a  thorough  hemo- 
stasis. Owing  to  its  hemolytic  property,  Dakin's  solu- 
tion has  the  power  of  dissolving  recent  blood-clots. 
A  poor  hemostasis  invites  the  danger  of  a  secondary 
hemorrhage. 

" Counter-openings  for  drainage  are  rarely  employed. 
If  the  necessity  for  their  use  should  arise,  one  should 
avoid  making  them  at  the  most  dependent  point,  as 
the  goal  of  technic  is  to  keep  the  liquid  in  contact  with 
all  the  surfaces  of  the  wound. 

"The  Introduction  of  the  Instillation  Tubes.— The 
guiding  principle  is  to  place  the  tubes  so  that  the 


THE  DAKIN-CARREL  METHOD 


51 


liquid  will  come  into  contact  with  every  portion  of 
the  wound.  The  placing  of  the  tubes  will  vary  with 
the  nature  of  the  wound. 

"Superficial  Wounds. — A  thin  layer  of  gauze  is 
placed  over  the  wound,  and  on  this  the  requisite  num- 
ber of  instillation  tubes.  The  tubes  are  secured  to  the 
wound-edges  by  a  rubber  cuff  and  suture  or  a  two- 
way-flow  tube  is  used.  If 
the  tubes  are  placed  di- 
rectly on  the  surface,  they 
become  encrusted  and  the 
orifices  are  blocked  with 
granulations.  Too  thick  a 
layer  of  gauze  should  not 
be  used,  as  it  will  become 
clogged  with  the  wound 
secretions  and  prevent  the 

Solution  from  reaching  the 
wminrl 

'  'Penetratl  ng  Wounds— 

In  the  simple  type,  a  tube 

without  lateral  perforations  is  introduced  to  the  depth 
of  the  cavity  and  the  solution  allowed  to  well  up  from 
the  bottom  (Fig.  14).  In  a  large  tract  terminating  in 
a  cavity  with  irregular  collapsible  walls  a  little  gauze 
is  introduced  to  support  the  walls  of  the  cavity  and 
allow  a  more  thorough  distribution  of  the  fluid.  Pen- 
etrating wounds  with  the  point  of  entrance  in  a  de- 
pendent position  (as  the  buttock,  posterior  surface  of 
the  extremities,  and  the  back)  are  treated  with  per- 


Fig.  14. — Showing  Carrel's  meth- 
od of  using  Dakin's  solution  in  an 
anterior  wound  and  keeping  the 
wound  full  of  the  solution  so  as  con- 
stantly to  attack  the  infecting  bac- 
teria (Carrel  and  Dehelly). 


TREATMENT  OF  WAR  WOUNDS 


f orated  tubes  dressed  with  toweling  (Fig.  16).  These 
dressed  tubes  keep  the  antiseptic  in  contact  with  the 
wound.  A  suitable  non-perforated  tube  can  also  be 
used. 


Fig.  15. — Showing  the  meth- 
od by  which  the  distributing  tube 
enters  the  wound  through  the 
dressing  without  being  con- 
stricted (Carrel  and  Dehelly). 


Fig.  16. — Mode  of  irrigating  a  wound 
in  a  posterior  position.  Observe  that  the 
distributing  tube  is  here  necessarily  sur- 
rounded with  toweling,  otherwise  the  fluid 
would  escape  almost  immediately.  This 
toweling  should  be  firmly  sewed  to  the  dis- 
tributing tube  by  silk  and  not  by  catgut,  so 
that  it  may  not  become  detached  and  be 
left  in  the  wound  (Carrel  and  Dehelly). 


"  Through-and-through  Wounds. — A  perforated  tube 
with  the  tied  extremity  uppermost  is  passed  from 
the  lower  to  the  upper  wound.  The  liquid,  escaping 
through  the  small  lateral  holes,  flows  back  along  the 
tract  to  the  inferior  orifice,  moistening  the  entire 
wound. 


THE  DAKIN-CARREL  METHOD 


53 


"Wounds  of  the  hand  or  foot,  open  amputation 
stumps,  etc.,  are  immersed  in  Dakin's  solution  for 
from  ten  to  fifteen  minutes  every  two  hours  until  the 
wound  is  sterilized.  The  skin  is  protected  by  smear- 
ing it  with  sterile  yellow  petrolatum. 


Fig.  17.— Showing  the  improper 
way  of  placing  the  distributing  tubes. 
They  are  in  contact  with  the  gauze  in- 
stead of  in  contact  with  the  wound 
(Carrel  and  Dehelly). 


Fig.  18. — The  correct  way  of  placing 
the  distributing  tubes  so  that  the  Dakin 
fluid  comes  directly  in  contact  with  all 
the  surfaces  of  the  wound  (Carrel  and 
Dehelly). 


"The  After-care  of  the  Wounds. — The  materials 
used  are  described  above.  In  the  care  of  the  wounds 
a  strict  instrumental  technic  is  employed,  the  gloved 
hands  never  coming  in  contact  with  the  wounds  or 
dressings. 


54  TREATMENT  OF  WAR  WOUNDS 

.  "Instillations  of  the  fluid  are  made  every  two  hours 
[day  and  night]  by  releasing  the  adjustable  clamp  [for 
a  second  or  two]  (Fig.  12)  controlling  the  flow.  The 
amount  of  solution  employed  varies  with  the  nature 
and  extent  of  the  wound;  for  the  average  wound, 
10  c.c.  are  sufficient.  This  interrupted  instillation  is 
kept  up  until  the  wound  is  proved  sterile.  The  tubes 
are  then  removed,  and  a  compress  moistened  with 
Dakin's  solution  is  applied.  Formerly  a  continuous 
instillation  was  the  method  of  choice:  if  used  at  all, 
it  should  be  discontinued  in  from  twenty-four  to 
forty-eight  hours.  The  rate  of  instillation  is  from  5 
to  20  drops  a  minute,  according  to  conditions.  The 
object  is  to  moisten  the  wound  surfaces  and  not  flood 
the  bed. 

"  Once  a  day — oftener,  if  necessary — the  wound,  the 
tubes,  and  the  flow  of  the  liquid  are  inspected.  Flush- 
ing the  wound  shows  if  the  solution  is  being  delivered 
as  planned,  and  mechanically  washes  away  the  excess 
of  wound  secretion. 

''The  Carrel  method  is  not  a  continuous  irrigation. 
It  is  a  mechanical  attempt  to  deliver  an  antiseptic  of 
definite  chemical  concentration  to  every  portion  of  a 
surgically  prepared  wound  and  to  insure  its  constant 
contact  for  a  prolonged  period 

"Systematic  Bacteriologic  Examination  of  the 
Wound. — This  consists  in  a  regular  determination  of 
the  number  of  microbes  on  the  wound  surfaces.  This 
is  done  by  transferring  with  a  standard  loop  a  portion 
of  the  secretion  to  a  slide  and  counting  the  number  of 


THE  DAKIN-CARREL  METHOD  55 

microbes  per  microscopic  field.  This  is  carried  out 
every  second  day,  and  the  results  are  entered  on  a 
suitable  chart.  When  the  microbes  are  absent  from 
the  wound  on  three  successive  counts,  the  wound  is 
considered  sterile.  Though  not  absolute,  the  bacte- 
riologic  control  is  of  great  practical  value  as  a  thera- 
peutic guide 

"It  is  better  to  begin  the  bacterial  chart  one  or  two 
days  after  the  reception  of  the  patient.  As  a  rule,  the 
germs  begin  to  appear  after  the  ninth  or  tenth  hour. 
There  is  an  initial  rise  on  the  second  or  third  day. 
This  remains  so  for  a  few  days,  and  then  the  descent 
begins.  Wounds  on  the  soft  parts  are  sterilized  in 
from  five  to  eight  days.  Greatly  traumatized  wounds 
require  a  longer  time.  Fractures  can  be  sterilized  in 
from  two  to  four  weeks.  If  sequestra  are  present, 
they  must  be  removed  to  obtain  an  asepsis. 

"Wounds  sterilized  by  the  Carrel  method  are  read- 
ily reinfected  if  the  treatment  is  stopped. 

"  Reunion  of  Wound. — When,  by  three  successive 
tests,  the  bacteriologic  examination  shows  the  wound 
to  be  sterile,  it  is  closed  by  careful  layer  sutures.  In 
the  favorable  cases  this  can  be  done  on  the  fifth  day. 
The  average  time  for  the  soft  parts  is  from  seven  to 
nine  days. 

"In  cases  in  which  sutures  cannot  be  employed  the 
wounds  are  closed  by  adhesive  straps  passed  in  such 
a  way  that,  besides  pulling  the  edges  of  the  wound 
together,  they  make  a  compression  around  the  whole 
circumference  of  the  limb,  or  a  'corset  lacing'  (Fig. 


56  TREATMENT  OF  WAR  WOUNDS 

19).     Care  must  be  taken  not  to  have  the  circular 
bandage,  if  this  be  used,  too  tight. 

"For  extensive  wounds  two  Canton-flannel  bands 
are  prepared,  the  length  to  be  slightly  longer  than  the 
wound,  the  breadth  to  be  a  little  less  than  half  the 
circumference  of  the  limb.  On  the  hemmed  edges 
shoe-hooks  are  inserted  every  2  cm.  The  limbs  are 
painted  up  to  the  edges  of  the  wound  with  a  resin 


Fig.  19. — The  edges  of  a  wound  being  drawn  together  by  rubber  elastic  traction 
(Carrel  and  Dehelly). 

varnish  or  Heusner's  glue  (see  page  160),  and  the 
woolly  side  of  the  Canton  flannel  applied.  One 
should  wait  until  the  traction  strips  are  firmly 
adherent  before  lacing  them  with  rubber  bands.  The 
tension  of  the  rubber  bands  rapidly  draws  the  wound 
edges  together." 

In  the  entire  treatment  of  these  wounds  even  the 
gloved  hands  never  are  allowed  to  touch  any  dressing 
or  the  wound.  Everything  is  handled  by  forceps, 
which  can  be  so  much  more  certainly  disinfected  than 
hands  or  even  gloves. 


THE  DAKIN-CARREL  METHOD 


57 


When  a  wound  has  filled  up  and  is  in  condition  to 
cicatrize,  Carrel  and  Count  du  Nouy,  a  French  physi- 
cist, by  means  of  a  "planimeter,"  are  able  to  measure 
the  exact  area,  i.  e.,  the  number  of  square  centimeters, 


Dec. 


Fig.  20.  —  On  December  17th  the  area  of  the  wound  was  16.2  sq.  cm.  A 
slight  infection  between  December  27th  and  29th,  when  one  microorganism  in 
two  microscopic  fields  was  found,  caused  a  slight  deviation  of  the  actual  curve 
from  the  calculated  curve.  (Kindness  of  Carrel  and  du  Noiiy  and  the  Jour. 
Exp.  Med.,  1916,  xxiv,  454.) 


in  the  most  irregular  wound.  The  number  of  square 
centimeters  is  entered  on  a  chart  (Figs.  20,  21,  22, 
vertical  numbers)  every  second  day.  The  dates  are 
entered  according  to  the  horizontal  numbers.  After 
three  or  four  observations  have  been  entered,  a  "curve 


58 


TREATMENT  OF  WAR  WOUNDS 


of  healing"  is  established.    By  prolonging  this  curve 
they  can  predict  with  almost  absolute  accuracy  the 


126 


100 


50 


Y 


\ 


7O 


Feb. 


7S  2O  22.2V  2G 


Fig.  21. — Wound  of  the  abdominal  wall.  The  horizontal  part  of  the  curve 
from  February  16th  to  18th  represents  a  period  of  slight  infection.  As  soon  as 
the  wound  was  sterilized  chemically  the  curve  descended  abruptly.  (Kindness 
of  Carrel  and  Hartman  and  the  Jour.  Exp.  Med.,  1916,  xxiv,  p.  437.) 

day   on   which   a  given  wound   will   be  completely 
healed.     It  is  remarkable  how  nearly  the  "actual" 


THE  DAKIN-CARREL  METHOD 


59 


curve  and  the  "calculated"  curve  in  a  normal  case 
coincide  (Fig.  20) .  Any  renewed  infection,  of  course, 
disturbs  this  curve,  but,  curiously  enough,  if  the  in- 


iflrea. 
Sq.cm, 
57 
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53 

55 
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29 
27 
25 
23 
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to 

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2 
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V 

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"> 

—  .-^ 

7     9  //  A3  f3  f7 /9  2S  23  Z5  2.7 Z9  3t  2    V    6    8   JO 
9Sl.  Feb. 

Fig.  22. — Shell  wounds  with  fracture  of  the  radius  and  ulna.  The  curves  of 
both  wounds  tend  to  unite.  Note  that  the  larger  wound,  33  sq.  cm.,  healed 
far  more  rapidly  than  the  smaller  wound,  which  was  less  than  1  sq.  cm.  on  the 
same  date.  (Kindness  of  Carrel  and  Hartman  and  the  Jour.  Exp.  Med.,  1916, 
xxiv,  p.  442.) 

fection  is  quickly  overcome,  the  healing  process 
undergoes  acceleration  and  the  healing  will  still  be 
brought  about  at  or  very  near  the  predicted  date. 


60  TREATMENT  OF  WAR  WOUNDS 

Of  course,  any  prolonged  infection  would  considerably 
delay  the  healing.  Another  curious  fact  brought  out 
by  these  curves  is  that  large  wounds  heal  much  more 
rapidly  than  small  wounds  (Fig.  22).  (The  whole 
subject  is  treated  at  length  in  the  Journal  of  Experi- 
mental Medicine,  1916,  vol.  xxiv,  pp.  451-470.) 

Since  this  text  was  written  I  have  been  privileged 
to  see  in  manuscript  the  paper  presented  at  the  Bos- 
ton meeting  of  the  American  Surgical  Association 
early  in  June,  1917,  by  H.  D.  Dakin,  Walter  Estell 
Lee,  Joshua  E.  Sweet,  Byron  M.  Hendrix,  and  Rob- 
ert G.  LeConte.  It  is  entitled  a  "Report  of  the  Use 
of  Dichloramin-T  (toluene-parasulphondichloramin) 
in  the  Treatment  of  Infected  Wounds." 

In  spite  of  its  immense  value,  three  valid  objections 
to  the  Carrel-Dakin  method  are  evident: 

1.  The  irritation  of  the  skin,  an  irritation  which 
sometimes  is  very  painful  and  may  persist  for  a  long 
time.  To  minimize  this  it  is  essential  not  only  to  pro- 
tect the  skin  by  vaselin,  but  that  minute  care  also 
be  taken  to  insure  the  exact  strength  of  the  solu- 
tion. Below  0.45  per  cent.  the.  germicidal  action  is 
too  feeble.  Above  0.50  per  cent,  the  solution  is  too 
irritating.  This  means  that  the  solution  must  be  most 
carefully  made  and  tested  and  that  fresh  solutions 
must  be  constantly  prepared. 


OBJECTIONS  TO  THE  METHOD  61 

2.  The  solutions,  when  in  contact  with  the  wound 
exudates,  lose  their  chlorin  in  an  hour  or  even  less 
time  and  become  inert.    Hence  the  need  of  a  new  sup- 
ply of  the  fluid  every  two  hours.     This  constant  care, 
day  and  night,  the  care  not  to  use  too  much  or  too 
little,  the  expense  of  so  much  solution,  apparatus,  and 
dressing,  etc.,  make  the  method  time-consuming  and 
costly.    Above  all,  it  requires  a  large  staff  of  doctors 
and  nurses. 

3.  In    order   to  obtain    the  maximum  germicidal 
effect  of  weak  hypochlorite  solutions  it  is  necessary 
to  keep  them  in  constant  contact  with  all  surfaces  of 
the  wound.     In  the  Dakin-Carrel  technic  this  is  ac- 
complished by  making  basin-like  cavities  of  all  the 
wounds,  which  means  that  dependent  drainage  must 
be  avoided. 

Accordingly,  Dakin  has  lately  suggested  the  use  of 
Dichloramin-T,  a  synthetic  chloramin  corresponding 
to  the  germicidal  chloramin  formed  when  the  nascent 
chlorin  of  the  hypochlorites  comes  in  contact  with  the 
wound  exudates.  Dichloramin-T  is  non-irritating  to 
the  skin.  Instead  of  using  this  as  ah  aqueous  solu- 
tion, as  was  first  employed  with  Chloramin-T,  it  is 
dissolved  in  chlorinated  eucalyptol  and  paraffin  oils. 
This  solution  can  be  used  in  5  per  cent,  and  even  of 
10  per  cent,  strength  instead  of  the  0.5  per  cent., 


62  TREATMENT  OF  WAR  WOUNDS 

and  the  germicidal  action  continues  for  eighteen  to 
twenty-four  hours.  The  solution  is  said  not  to  af- 
fect the  body  cells,  even  in  the  stronger  percentages. 

The  dressing,  therefore,  is  done  only  once  a  day; 
the  technic  is  much  simpler  than  the  earlier  one,  and 
permits  dependent  drainage.  There  is  a  great  saving 
of  material,  and,  what  is  of  greater  consequence,  the 
time  given  to  each  case,  except  at  the  primary  opera- 
tion or  dressing,  is  greatly  reduced. 

At  the  Pennsylvania  Hospital  in  Philadelphia  Dr. 
Dakin's  colleagues,  in  the  paper  referred  to,  have 
made  comparative  clinical  tests,  with  the  following 
results : 

In  160  unselected  cases  of  industrial  accidents 
treated  by  the  Dakin-Carrel  method  the  Dakin- 
Carrel  cases  were  discharged  in  one-third  of  the 
time  required  by  former  methods  (as  obtained  from 
the  industrial  insurance  statistics  of  similar  cases  in 
other  Philadelphia  hospitals) — a  great  advantage. 

In  82  similar  unselected  cases  treated  in  the  same 
clinic  by  the  Dichloramin-T-in-oil  method  they  were 
discharged  in  16.3  per  cent,  less  time  than  by  the 
Dakin-Carrel  method — a  still  better  result.  These 
results,  however,  were  obtained  under  the  favorable 
conditions  of  civil  life,  in  a  first-class  hospital,  and  in 
the  absence  of  the  intense  infection  seen  in  the  pres- 
ent war. 


DICHLORAMIN-T  63 

For  details  of  preparation  and  surgical  treatment 
by  the  Dichloramin-T-in-oil  method  the  reader  must 
refer  to  the  paper  mentioned*  and  later  papers  which 
will  appear  stating  the  experience  of  those  who  have 
used  the  method.  Undoubtedly  they  will  report 
frankly  the  good,  bad,  or  indifferent  results,  as  the 
case  may  be.  So  marked  a  change  in  treatment 
must  run  the  gauntlet  of  criticism  by  many  shrewd 
and  careful  observers.  A  final  judgment  must  be 
reserved  until  many  surgeons  have  thoroughly  tested 
the  method.  The  method,  as  ought  to  be  the  case, 
has  been  freely  given  to  the  profession  and  the  public. 

The  following  are  the  directions  for  preparing  the 
solution.  Any  good  chemist  can  make  it. 

Those  who  are  technically  interested  are  referred 
to  the  chemical  papers  by  Kastle,  Kaiser,  and  Bradyf 
and  Chattaway.J 

PREPARATION  OF  DICHLORAMIN-T 

The  following  details  were  worked  out  for  Chatta- 
way's  method  of  preparation: 

Chlorinated  lime  (from  350  to  400  gm.)  of  good 
quality  is  shaken  with  2  liters  of  water  on  a  shaker  for 

*  Jour.  Amer.  Med.  Assoc.,  July  7,  1917,  and  Trans.  Amer. 
Surg.  Assoc.,  1917. 

f  Amer.  Chem.  Jour.,  1896,  xviii,  491. 

t  Jour.  Chem.  Soc.  London,  1905,  Ixxxvii  (1),  145. 


64  TREATMENT  OF  WAR  WOUNDS 

half  an  hour,  and  then  the  mixture  allowed  to  settle. 
The  supernatant  fluid  is  siphoned  off  and  the  remain- 
der filtered. 

Powdered  toluene-parasulphonamid,  75  gm.  (the 
crude  product  may  be  used),  is  then  added  to  the 
whole  of  the  hypochlorite  solution  and  shaken  till 
dissolved.  The  mixture  is  filtered,  if  necessary,  placed 
in  a  large  separating  funnel,  and  acidified  by  the 
gradual  addition  of  acetic  acid  (100  c.c.).  Chloro- 
form (about  100  c.c.)  is  then  added  to  extract  the 
dichloramin,  and  the  whole  is  well  shaken.  The  chlo- 
roform layer  is  tapped  off,  dried  over  calcium  chlorid, 
filtered,  and  allowed  to  evaporate  in  the  air.  The 
residue  is  powdered  and  dried  in  vacuo.  It  is  suffi- 
ciently pure  for  most  purposes  without  recrystalliza- 
tion. 

The  sodium  toluene-parasulphochloramin  which  is 
sold  under  the  trade  name  of  chlorazene  may  be  used 
instead  of  the  toluene-parasulphonamid. 

A  SECOND  METHOD  OF  PREPARING  DICHLORAMIN-T 

Fifty  gm.  of  para-toluenesulphonamid  are  dissolved 
in  500  c.c.  of  water,  and  100  gm.  of  sodium  acetate 
and  100  c.c.  of  chloroform  are  added.  The  container 
is  immersed  in  cold  water,  and  a  rapid  stream  of 
chlorin  is  passed  in  until  the  mixture  is  saturated. 
The  mixture  is  allowed  to  stand  a  few  hours,  and  if 
the  odor  of  chlorin  disappears,  more  of  the  gas  is 
passed  in.  If  necessary,  more  chloroform  can  be 
added  to  dissolve  the  dichloramin.  From  this  point 
the  procedure  is  the  same  as  in  the  preceding  method. 


EUCALYPTOL  AND  PARAFFIN  OIL  65 

PREPARATION  OF  CHLORINATED  EUCALYPTOL 

Eucalyptol  (U.  S.  P.),  not  eucalyptus  oil,  must  be 
used.  Five  hundred  c.c.  are  treated  with  15  gm.  of 
potassium  chlorate  and  50  c.c.  of  concentrated  hydro- 
chloric acid.  After  twelve  hours  the  oil  is  well  washed 
with  water  and  sodium  carbonate  solution.  Dry  so- 
dium carbonate  is  added  to  the  oil,  and  the  mixture 
is  allowed  to  stand  twenty -four  hours.  It  is  then 
filtered  and  dried  with  a  little  calcium  chlorid. 

PREPARATION  OF  CHLORINATED  PARAFFIN  OIL 

Five  hundred  c.c.  of  commercial  liquid  petrolatum 
are  treated  with  15  gm.  of  potassium  chlorate  and  50 
c.c.  of  concentrated  hydrochloric  acid.  The  mixture 
is  exposed  to  the  light  and  allowed  to  stand  over  night. 
It  is  then  put  into  a  separatory  funnel,  and  washed 
successively  with  water,  sodium  chlorid  solution,  and 
water.  The  opalescent  oil  is  tapped  off,  a  lump  or 
two  of  calcium  chlorid  and  5  gm.  of  charcoal  are 
added,  and  the  oil  is  filtered  with  suction. 

In  order  to  determine  the  amount  of  liquid  petro- 
latum which  can  be  added  to  the  eucalyptol  solution 
of  dichloramin-T  the  following  mixtures  were  made: 

Solution  1 :  1  part  liquid  petrolatum  to  2  parts  15  per  cent, 
eucalyptol  solution. 

Solution  2:  1  part  liquid  petrolatum  to  1  part  15  per  cent, 
eucalyptol  solution. 

Solution  3 :  3  parts  liquid  petrolatum  to  5  parts  15  per  cent, 
eucalyptol  solution. 

Solution  4:  2  parts  liquid  petrolatum  to  1  part  15  per  cent, 
eucalyptol  solution. 

5 


66  TREATMENT  OP  WAR  WOUNDS 

These  solutions  were  placed  in  test-tubes,  stoppered 
tightly,  and  preserved  in  the  refrigerator  at  about  0° 
C.  All  solutions  became  somewhat  turbid  as  soon  as 
the  liquid  petrolatum  had  been  added,  but  in  forty- 
eight  hours  there  was  no  appreciable  settling  out  in 
any  case.  After  a  week,  however,  the  dichloramin-T 
had  partially  crystallized  from  Solutions  3  and  4. 
Solutions  1  and  2  were  no  more  turbid  than  just  after 
the  addition  of  the  liquid  petrolatum,  and  none  of  the 
dichloramin-T  had  crystallized  out. 

This  experiment  seems  to  justify  the  conclusion 
that  no  more  than  an  equal  part  of  liquid  petrolatum 
should  be  added  to  a  15  per  cent,  solution  of  dichlor- 
amin-T in  eucalyptol  when  the  solution  is  to  be  kept 
for  any  length  of  time,  but  when  the  mixture  is  to 
be  used  immediately,  as  much  as  two  parts  of  liquid 
petrolatum  to  one  of  the  15  per  cent,  eucalyptol  solu- 
tion may  be  used. 

We  have  used  a  solution  made  up  of  one  part  of 
liquid  petrolatum  and  two  parts  of  15  per  cent,  solu- 
tion of  the  dichloramin-T  in  eucalyptol.  A  larger 
proportion  of  the  liquid  petrolatum  would  make  the 
mixture  somewhat  cheaper,  but  would  have  no  other 
apparent  advantage. 

One  sample  of  chlorinated  eucalyptol  and  two  sam- 
ples of  chlorinated  liquid  petrolatum,  one  of  which 
was  chlorinated  in  the  sunlight  and  the  other  on  a 
cloudy  day,  were  analyzed  for  chlorin  by  Carius' 
method,  with  the  following  results: 


EFFECT  OF  SUNSHINE  AND  SHADE  67 

Chlorinated  eucalyptol : 

0.1044  gm.  oil  gave  0.0044  gm.  AgCl  =  1.04  per  cent.  Cl. 

Liquid  petrolatum  chlorinated  on  a  cloudy  day: 
0.0936  gm.  oil  gave  0.0052  gm.  AgCl  =  1.37  per  cent.  Cl. 

Liquid  petrolatum  chlorinated  in  sunlight: 
0.1510  gm.  oil  gave  0.0231  gm.  AgCl  =  3.78  per  cent.  Cl. 

The  amount  of  chlorin  which  the  oils  take  up  is  not 
large,  but  the  amount  absorbed  is  equivalent  to  a 
very  considerable  portion  of  chlorin  which  would  be 
available  from  a  10  per  cent,  solution  of  the  dichlor- 
amin-T. 


REMOVAL  OF  FOREIGN  BODIES 

The  removal  of  foreign  bodies  with  the  aid  of  fluoros- 
copy  has  proved  so  successful  in  the  present  war  that 
I  think  it  well  to  direct  especial  attention  to  the  pos- 
sibilities of  attaining  still  greater  efficiency  and  ac- 
curacy by  the  use  of  stereo-fluoroscopj^.  I,  therefore, 
asked  Dr.  E.  W.  Caldwell  to  make  the  following  brief 
statement  of  the  general  principles  underlying  it. 

By  his  earlier  thorough  training  as  an  electrical  ex- 
pert, and  later  his  study  of  medicine,  he  is  especially 
competent  to  consider  this  subject.  I  understand 
that  he  has  perfected  earlier  methods  and  is  still  mak- 
ing improvements  in  the  technic. 


STEREO-FLUOROSCOPY  IN  THE  LOCALIZATION  AND  EXTRACTION 

OF  FOREIGN  BODIES 
BY  E.  W.  CALDWELL,  M.D. 

New  York  City 

"There  are  many  cases  of  injury  by  a  foreign  body 
in  which  the  #-ray  localization  can  be  best  made  on 
plates,  but  experience  in  the  military  hospitals  of 
Europe  sho\vs  that  in  most  cases  the  fluorescent 
screen  method  is  preferable.  These  fluoroscopic  local- 
izations are  carried  out  sometimes  before  the  opera- 

68 


REMOVAL  OF  FOREIGN  BODIES  69 

tion  for  removal,  and  sometimes  in  connection  with 
the  operation.  The  advantages  of  the  last-mentioned 
method  seem  to  compensate  for  its  disadvantages, 
which  are:  First:  The  danger  of  infecting  the  field 
from  the  use  of  the  x-ray  apparatus.  Second:  The 
necessity  for  operating  in  a  fairly  dark  room  in  order 
to  see  the  fluorescent  screen  clearly.  Third:  The 
danger  incident  to  the  use  of  certain  anesthetics  in 
close  proximity  to  electric  sparks. 

"The  use  of  the  fluorescent  screen  during  operation 
is  seldom  needed,  except  in  war  surgery,  and  this  pro- 
cedure calls  for  refinements  and  improvements  in 
technic  and  apparatus  which  in  times  of  peace  have 
not  been  fully  developed. 

"The  most  serious  defect  of  the  x-ray  project  ion  is 
that  it  is  essentially  a  shadow,  and  not  an  image,  and 
while  it  gives  us  fairly  accurate  ideas  of  length  and 
breadth,  there  is  ordinarily  no  indication  of  depth, 
such  as  is  present  in  a  photographic  image. 

"This  defect  has  been  remedied  by  the  use  of  the 
stereoscope,  or  double-shadow  method,  first  proposed 
by  Elihu  Thomson  early  in  1896,*  and  first  carried 
into  practice  by  Sir  James  Mackenzie  Davidson  in 
London. 

"  Stereoscopic  x-ray  plates  have  been  in  practical  use 
since  Davidson's  first  publication,  and  have  been  in- 
creasing in  popularity  in  recent  years.  The  stereo- 
fluoroscope  was  used  experimentally  by  Davidson, 

*  New  York  Electrical  Review. 


70  TREATMENT  OF  WAR  WOUNDS 

myself,  and  others  more  than  sixteen  years  ago,  but 
it  has  not  yet  come  into  general  use.  This  valuable 
accessory  to  the  fluorescent  screen  seems  about  to  be 
reduced  to  practice,  and  promises  to  be  very  helpful 
in  the  localization  of  foreign  bodies,  especially  by  the 
method  of  Sutton,  in  which  a  cannula  containing  a 
steel  wire  is  pushed  through  the  tissues  under  the 
guidance  of  the  fluorescent  screen  until  it  is  in  con- 
tact with  the  foreign  body. 

"With  the  ordinary  fluoroscopic  method,  which 
gives  no  perception  of  depth,  it  is  rather  difficult  to 
tell  when  the  needle  is  approaching  the  foreign  body. 
The  stereo-fluoroscope,  however,  shows  the  relation 
of  the  exploring  needle  to  the  foreign  body  as  ac- 
curately as  it  could  be  seen  if  exposed  in  the  open  air. 

:'The  process  of  obtaining  a  stereo-fluoroscopic 
image  is  much  more  complicated  than  that  of  simple 
fluoroscopy,  but  recent  improvements  in  the  x-ray 
tubes  have  removed  many  of  the  difficulties  which 
existed  in  the  first  experiments  some  fifteen  or  eigh- 
teen years  ago. 

"In  order  to  obtain  the  stereo-fluoroscopic  image  it 
is  necessary  to  use  two  sources  of  x-ray,  separated  by 
a  distance  of  a  few  inches,  and  to  present  to  each  eye 
the  simple  flat  projection  produced  on  the  screen  by 
one  of  these  sources  of  x-ray.  This  is  accomplished 
by  exciting  alternately  the  two  sources  of  x-ray  (ordi- 
narily two  small  tubes  placed  side  by  side)  and  mov- 
ing in  front  of  the  eyes  a  shutter  wrhich  is  synchronous 
with  the  alterations  in  the  source  of  the  x-ray,  so  that 


REMOVAL  OF  FOREIGN  BODIES  71 

when  the  right  eye  sees  the  projection  from  the  left 
x-ray  tube  the  shutter  cuts  off  the  vision  of  the  left 
eye.  Conversely,  when  the  left  eye  sees  the  projec- 
tion from  the  right-hand  x-ray  tube,  the  shutter  cuts 
off  the  view  from  the  left.  Each  eye,  therefore,  sees 
a  slightly  different  projection,  and  the  effect  is  that 
of  two-eye  vision,  which  gives  a  conception  of  the 
depth  that  is  not  obtained  from  the  simple  fluoro- 
scopic  shadow. 

"In  practice  the  flashes  of  the  x-ray  from  each  tube 
must  follow  each  other  so  rapidly  that  the  resulting 
x-ray  shadow  appears  to  be  continuous.  This  re- 
quires a  frequency  of  at  least  15  or  16  impulses  per 
second,  and  it  is  often  convenient  to  use  as  many 
as  60  per  second,  which  is  the  frequency  of  the  usual 
commercial  alternating  current  lighting  circuit. 

'The  first  apparatus  of  this  kind,  devised  by  Sir 
James  Mackenzie  Davidson,*  made  use  of  two  induc- 
tion coils  with  a  mercury  interrupter,  operated  by  a 
small  electric  motor.  To  the  shaft  of  the  motor  was 
connected  a  rotating  disc  shutter  with  properly  placed 
slots,  permitting  each  eye  to  see  alternately  and  in 
synchronism  with  the  alternating  excitation  of  the 
two  x-ray  tubes. 

"In  this  apparatus  the  position  of  the  shutter  had 
to  be  fixed  because  of  its  mechanical  connection  with 
the  rest  of  the  apparatus.  Boaz  and  others  used  a 
flexible  shaft  for  rotating  the  shutter  and  obtained 
some  degree  of  mobility.  My  own  first  contribution 
*  Archives  of  the  Roentgen  Ray,  January,  1901. 


72  TREATMENT  OF  WAR  WOUNDS 

to  the  art*  consisted  in  the  use  of  a  single  tube  with 
separated  foci,  and  in  the  use  of  an  electrically  oper- 
ated shutter,  which  was,  therefore,  freely  movable  and 
could  be  attached  to  the  eye-piece  of  the  ordinary 
fluoroscope.  The  alternating  excitations  of  the  tube 
were  obtained  by  making  use  of  an  alternating  cur- 
rent. The  wave  in  one  direction  excited  one  source 
of  x-ray,  and  the  wave  in  the  other  direction  excited 
the  other  source  of  x-ray.  The  moving  shutter  formed 
the  rotor  of  a  small  synchronous  electric  motor  oper- 
ated from  the  same  alternating  current  circuit  which 
supplied  current  for  the  x-ray  tube.  At  the  present 
time  this  is  the  most  convenient  shutter  available. 

"In  the  last  few  years  the  development  of  the  Coo- 
lidge  tube,  which  can  be  operated  perfectly  from  a 
high-tension  alternating  current,  has  made  this  prob- 
lem very  much  simpler. 

"Improved  methods  of  supporting  the  tubes,  the 
fluorescent  screen,  and  the  shutter  have  been  devel- 
oped within  the  last  few  months,  and  it  is  hoped  that 
in  spite  of  its  complexity  the  apparatus  may  materi- 
ally assist  in  the  surgical  removal  of  foreign  bodies." 


In  Makins'  paperf  he  and  Major  Curtis  consider 
quite  fully  the  use  of  radioscopy  and  stereo-fluoros- 
copy.  They  include  also  a  consideration  of  the 

*  New  York  Electric  Review,  November  16,  1901. 
|  Brit.  Med.  Jour.,  June  16,  1917. 


REMOVAL  OF  FOREIGN  BODIES  73 

method  of  localization  of  foreign  bodies  by  combining 
radiography  and  sectional  anatomy,  as  described  by 
Captain  Crymble.*  See  also  another  important  paper 
by  Eastman  and  Bettman.f 

*  Brit.  Jour.  Surg.,  October,  1915. 
f  Annals  of  Surgery,  July,  1917. 


TETANUS 

The  infection  of  the  soil  and  of  the  skin  and  clothes, 
the  sealing  of  the  wounds  from  drying  of  the  blood, 
when  speedy  access  to  the  first-aid  station  is  impos- 
sible, so  creating  an  anaerobic  condition  in  the  wound, 
the  rapid  growth  of  the  bacteria  in  twenty -four  hours 
or  more  in  such  favorable  conditions  (vide  supra),  all 
combined  to  cause  many  cases  of  tetanus  in  the  early 
months  of  the  war.  In  our  Civil  War  the  mortality 
was  89.3  per  cent.;  in  the  Franco-Prussian  War,  90 
per  cent.  Ashhurst  and  John,*  in  a  paper  covering 
435  cases  from  1897-1911,  reported  by  13  authors, 
still  showed  a  mortality  of  60  per  cent.  In  the  early 
stages  of  the  present  war  there  were  necessarily  many 
cases,  because  of  lack  of  the  tetanus  antitoxin  in  suffi- 
cient quantities  for  such  huge  masses  of  wounded. 
At  that  time,  too,  the  imperative  need  of  an  early  pro- 
tective inoculation  had  not  been  driven  deep  into 
the  minds  of  surgeons,  as  has  been  the  case  later. 
Now  every  wounded  man  receives  a  protective  inocu- 
lation at  the  very  first  possible  moment.  As  Gibson 

*  Amer.  Jour.  Med.  Sci.,  June,  1913. 

74 


TETANUS  75 

insists,  to  wait  for  the  symptoms  of  trismus  is  to  court 
disaster.  "Expect  tetanus  in  all  wounds  and  prevent 
its  onset"  is  the  rule,  and  the  result  has  been  that 
lockjaw  has  practically  disappeared  in  the  armies  on 
both  sides,  unless  in  some  distant  post  where  the 
supply  fails  or  when  the  patient  receives  the  pro- 
tective inoculation  too  late. 

Now  that  the  immediate  injection  of  the  antite- 
tanic  serum  is  universally  practised  by  the  surgeons 
in  the  armies  on  both  sides,  tetanus  is  relatively  rare. 
Cases  occur  singly,  rather  than  by  dozens  or  scores. 
This  conquest  of  tetanus  is  one  of  the  notable  vic- 
tories of  the  war. 

One  peculiar  phase  of  infection  has  been  noted  by 
Moynihan  and  others,  viz.,  "the  inordinate  length  of 
time  microorganisms  may  remain  in  the  tissues  long 
after  healing  is  complete"  and  then  cause  acute  infec- 
tion. Even  after  trivial  operations  for  the  removal 
of  foreign  bodies,  or  even  for  passive  movements,  tet- 
anus may  set  in  unexpectedly.  "Delayed  tetanus" 
and  "delayed  gas  infection"  are  not  very  uncommon. 

Bowling*  records  three  cases  under  treatment   at 

one  time,  delayed  until  the  fortieth,  fifty-first,  and 

fifty-third  days.    In  the  forty-day  case  not  only  did 

tetanus  set  in  after  this  period,  but  seventy-three  days 

*  Brit.  Med.  Jour.,  March  4,  1916,  p.  337. 


76  TREATMENT  OF  WAR  WOUNDS 

after  the  wound  had  been  received,  and  forty-two 
days  after  it  had  healed,  gas  gangrene  also  supervened 
and  caused  his  death.  Meantime  his  tetanus  had 
yielded  after  the  administration  of  a  total  of  189,500 
units.  No  operative  interference  had  occurred  to  light 
up  these  two  infections.  The  other  two  cases  had 
received  antitetanic  injections^one  at  an  uncertain 
interval,  the  other  two  days  after  being  wounded. 
Probably  none  had  been  given  to  the  first  (the  fatal) 
case.  Both  of  the  other  cases  followed  slight  opera- 
tions— one  sixteen  days  after  the  mere  opening  of 
an  abscess,  the  other  four  days  after  the  removal  of 
some  clothing  and  part  of  the  casing  of  a  bullet. 

In  animals  anaphylaxis  following  a  second  injection 
of  the  same  serum  is  well  known.  But  in  man  this  is 
much  less  to  be  feared.  Still,  provision  should  be 
made  to  prevent  its  occurrence.  It  may  follow  a 
second  dose  of  the  antitetanic  serum  when  this  is 
given  at  an  interval  of  ten  to  twelve  days  after  the 
first  dose.  If,  therefore,  ten  or  twelve  days  after  a 
prophylactic  dose  of  the  serum  has  been  given,  tet- 
anus is  threatened,  the  serum  should  be  adminis- 
tered in  fractional  doses  as  follows:  Instead  of  a  full 
dose,  an  injection  of  only  two  or  three  drops  of  the 
serum  in  solution  should  be  given;  if  no  ill  results 
follow  again  within  ten  minutes  more,  the  full  dose 


TETANUS  77 

may  then  be  administered.  Fractional  doses  should 
be  the  rule  when  any  operations — even  minor  ones, 
such  as  described  above — have  to  be  done  after  an 
interval  of  ten  to  twelve  days.  If  shock  should 
occur,  a  few  minims  of  a  1 : 1000  solution  of  adrenalin 
may  be  given  hypodermically  if  the  shock  is  not 
severe,  but  intravenously  if  it  is  at  all  alarming. 

I  append  the  Memorandum  on  Tetanus  issued  by 
the  British  War  Office  Committee  on  the  Study  of 
Tetanus:*  The  necessity  of  several  successive  pro- 
tective doses  is  properly  emphasized. 


MEMORANDUM  ON  TETANUS 

"  The  Prophylactic  or  Preventive  Treatment  of  Tetanus. 
-The  prophylactic  value  of  injections  of  antitetanic 
serum  is  beyond  all  question,  but  there  is  strong  ex- 
perimental evidence  that  in  about  ten  days  the  im- 
munity conferred  by  the  primary  injection  is  to  a 
great  extent  lost. 

"It  is,  therefore,  the  general  opinion  that  a  second 
subcutaneous  injection  should  be  given  in  all  cases  of 
septic  wounds,  and  in  order  to  anticipate  the  total 
disappearance  of  the  antitoxin  from  the  body  the 
second  injection  should  follow  the  first  at  an  interval 
of  seven  days. 

"  In  cases  of  long-continued  septic  wounds,  particu- 

*  Brit.  Med.  Jour.,  November  11,  1916,  p.  647. 


78  TREATMENT  OF  WAR  WOUNDS 

larly  those  caused  by  shell  or  bomb,  third  and  fourth 
injections  at  seven-day  intervals  are  recommended. 

"It  is  self-evident  that  if  it  is  considered  necessary 
to  give  a  second  injection,  then  it  is  equally  necessary 
to  give  a  third  or  a  fourth  or  further  prophylactic  in- 
jections, as  the  passive  immunity  conferred  by  the 
antitetanic  serum  is  of  short  duration. 

"  It  may  be  definitely  stated  here  that  the  danger  of 
anaphylactic  shock  is  negligible  when  prophylactic 
doses  of  500  U.  S.  A.  units  contained  in  3  cm.  of  horse 
serum  are  given  subcutaneously,  whatever  the  inter- 
val after  the  preceding  injection. 

"Dosage  in  Prophylactic  or  Preventive  Treatment  of 
Tetanus. — The  primary  injection  should  consist  of  500 
U.  S.  A.  units,  and  the  second  and  following  injections 
should  be,  for  the  present,  of  the  same  amount. 

"  The  primary  injection  is  given,  as  a  rule,  at  a  dress- 
ing station  or  field  ambulance  as  soon  as  the  wounded 
soldier  is  removed  from  the  firing  line.  The  second 
and  following  injections  will  most  frequently  be  given 
at  home  hospitals.  The  ordinary  phial  usually  con- 
tains 1500  units  of  tetanus  antitoxin.  One-third  of  a 
phial  should,  therefore,  be  injected  into  each  wounded 
man.  There  is  no  necessity  to  sterilize  the  syringes 
after  each  injection — the  serum  is  aseptic,  and,  more- 
over, contains  an  antiseptic;  it  will  be  sufficient  if  a 
freshly  sterilized  needle  is  used  for  each  case. 

"Precautions  to  be  Taken  Before  Operating  on 
Wounds. — When  operations  are  performed  at  the  site 
of  wounds,  even  if  they  are  healed,  a  prophylactic 


TETANUS  79 

injection  of  serum  should  invariably  be  given  if  the 
operation  be  performed  at  a  greater  interval  than 
seven  days  from  the  last  injection.  Cases  have  oc- 
curred in  which  the  performance  of  simple  operations 
has  been  followed  by  an  attack  of  tetanus,  although 
in  many  cases  the  primary  wound  had  been  healed 
several  weeks  before  the  operation. 

:'This  precautionary  injection  may  consist  of  a 
single  subcutaneous  injection  of  the  ordinary  prophy- 
lactic dose  of  500  units,  given,  when  possible,  two 
days  before  the  operation. 

"It  is  better  to  give  it  two  days  before  the  opera- 
tion, as  it  takes  some  forty-eight  hours  for  antitoxin 
to  be  fully  absorbed  after  subcutaneous  injection. 
Injected  intramuscularly,  the  absorption  is  quicker, 
—said  to  be  about  twelve  hours, — so  that  this  method 
could  be  used  if  time  is  pressing. 

"Of  course,  a  larger  dose  than  500  units  may  be 
injected  if  thought  advisable. 

"Antiseptics  Which  May  be  of  Use  in  the  Preventive 
Treatment  of  Tetanus. — The  group  of  oxidizing  anti- 
septics, such  as  hydrogen  peroxid,  potassium  per- 
manganate, chlorin  water,  and  solution  of  iodin,  are 
particularly  unfavorable  to  the  anaerobic  growth  of 
the  tetanus  bacillus.  They  have  the  power  of  render- 
ing toxin  non-toxic. 

''Diagnosis. — The  classic  symptoms  of  tetanus  as 
described  in  the  majority  of  the  text-books  refer  to  a 
phase  of  the  disease  when  treatment  has  already  lost 
much  of  its  value.  With  many  medical  men  tetanus 


80  TREATMENT  OF  WAR  WOUNDS 

is  not  tetanus  until  the  symptoms  of  risus  sardonicus 
and  lockjaw  are  present. 

"  In  those  who  have  been  protected  by  prophylactic 
injection  of  antitoxin  trismus  and  general  symptoms 
practically  never  occur,  and  the  manifestations  of 
tetanus  are  confined  to  local  spastic  rigidity  of  the 
wounded  limb,  which  may  persist  for  weeks. 

"The  early  diagnosis  of  tetanus  is  of  the  greatest 
importance.  All  clinical  and  experimental  evidence 
tends  to  show  that  the  chances  of  successful  treat- 
ment diminish  rapidly  with  the  length  of  time  after 
the  first  symptoms  are  observed. 

"Tetanus  toxin  reaches  the  motor  nerve  cells  by 
traveling  up  the  nerves.  It  is  not  directly  conveyed 
to  the  central  nervous  system  by  the  blood.  In  a 
large  number  of  cases  the  toxin  appears  to  reach  the 
spinal  cord  primarily  by  the  nerves  which  are  in  con- 
nection with  the  seat  of  the  injury,  and  hence  the 
motor  nerve  cells  governing  the  muscles  round  about 
the  wound  will  be  the  earliest  affected,  such  affection 
showing  itself  in  the  form  of  spasticity  and  increased 
reflex  excitability  of  the  muscles  near  the  wound.  In 
some  cases  these  symptoms  may  precede  other  symp- 
toms of  tetanus  by  many  hours.  It  is,  therefore, 
desirable  that  the  muscles  in  the  vicinity  of  the  wound 
should  be  examined  whenever  dressings  are  removed, 
and  the  occurrence  of  rigidity  or  twitchings,  or  local 
increased  reflex  response  to  gentle  tapping  or  pres- 
sure, immediately  reported  to  the  surgeon  in  charge. 

"All  nursing  sisters  engaged  in  dressing  wounds 


TETANUS  81 

should  be  warned  to  give  the  alarm  if  the  muscles  round 
the  wound  are  harder  or  more  rigid  than  the  muscles  of 
the  uninjured  limb  or  side 

"Therapeutic  or  Curative  Treatment  of  Tetanus. — It 
cannot  be  too  strongly  emphasized  that  time  is  the 
all-important  element  in  the  treatment  of  tetanus. 
As  short  a  time  as  possible  should  be  allowed  to 
elapse  between  the  diagnosis  and  the  commencement 
of  active  treatment.  A  delay  of  an  hour  may  make 
all  the  difference  between  success  and  failure. 

"It  is  on  this  account  that  the  early  symptoms  are 
of  the  greatest  importance.  In  almost  every  case  of 
tetanus  there  are  found  local  manifestations  of  the 
disease,  very  often  hardness  and  rigidity  of  the  mus- 
cles around  the  wound,  and  these  signs  can  be  seen  or 
felt  for  days  or  even  weeks  before  the  occurrence  of 
trismus.  In  a  case  on  record  these  local  symptoms 
had  been  present  for  three  weeks  before  the  trismus 
showed  itself  and  before  tetanus  was  suspected.  One 
medical  officer  is  reported  to  have  said  that  symptoms 
of  tetanus  were  present  in  a  case  but  were  not  suffi- 
ciently severe  to  justify  the  use  of  antitoxin !  Accord- 
ing to  present  ideas,  it  should  no  longer  be  permissible 
to  wait  for  the  occurrence  of  lockjaw  before  pro- 
nouncing the  word  tetanus;  5000  units  of  antitoxic 
serum  are  of  more  avail  at  the  very  beginning,  when 
the  disease  is  still  localized,  than  50,000  when  the 
symptoms  have  become  general.  The  moment,  then, 
that  any  local  manifestation  of  tetanus  is  observed, 

6 


82  TREATMENT  OF  WAR  WOUNDS 

it  is  recommended  to  proceed  at  once  to  vigorous 
specific  treatment. 

"The  treatment  of  tetanus  may  be  divided  into 
specific  and  symptomatic: 

"1.  Specific. —  Specific  treatment  consists  in  the 
giving  of  tetanus  antitoxin,  which  has  the  power  of 
rendering  the  tetanus  toxin  with  which  it  comes  in 
contact  non-poisonous.  From  what  has  been  said 
above  about  the  injurious  effect  of  delay,  it  is  obvious 
that  it  is  necessary  to  give  antitoxin  by  the  method 
which  enables  it  to  produce  its  effect  most  quickly. 
Subcutaneous  injections  of  serum  are  absorbed  very 
slowly;  forty-eight  hours  may  elapse  before  a  dose  is 
fully  absorbed;  hence  little  can  be  expected  from  this 
method  at  the  beginning  of  treatment. 

"Experimental  and  clinical  evidence  has  shown 
that  the  best  results  are  attained  by  intrathecal  in- 
jections of  serum.  (See  Appendix.) 

"This  direct  attack  on  the  toxin  in  the  neighbor- 
hood of  the  central  nervous  system  should  be  sup- 
plemented by  intramuscular  injections  in  order  to 
neutralize  any  toxin  in  the  blood,  and  thus  prevent 
any  more  of  it  being  taken  up  by  the  nerve-endings 
in  muscle.  Absorption  of  antitoxin  from  muscle  is 
rapid,  reaching  its  maximum  in  about  twelve  hours. 

"In  addition  to  the  intramuscular  method  sub- 
cutaneous injections  can  be  practised  at  any  time, 
and  is  particularly  useful  in  the  later  stages  in  keep- 
ing up  the  antitoxic  quality  of  the  blood.  Absorp- 
tion reaches  a  maximum  in  two  or  three  days. 


TETANUS  83 

"It  is  recommended  that  intravenous  injections 
should  not  be  made,  as  the  risks  of  anaphylactic 
trouble  occurring  are  greater  when  serum  is  given 
intravenously  than  when  it  is  given  by  any  other 
route. 

"Dosage  in  the  Treatment  or  Curative  Treatment  of 
Tetanus. — When  given  curatively,  antitoxic  serum 
must  be  administered  in  very  large  doses. 

"In  a  case  of  tetanus  the  first  thing  to  do  is  to 
give  an  intrathecal  injection  of  antitoxin. 

"The  amount  of  cerebrospinal  fluid  which  can  be 
withdrawn  will,  as  a  rule,  not  be  more  than  20  c.c. 
It  is  usually  held  to  be  undesirable  to  run  in  more 
serum  than  will  replace  the  cerebrospinal  fluid  drawn 
off,  and  in  the  cases  when  little  or  no  fluid  can  be 
withdrawn  it  is  not  wise  to  inject  more  than  20  c.c. 
of  serum,  and  this  very,  very  slowly. 

"If  the  serum  used  be  of  the  ordinary  strength  of 
150  units  in  one  c.c.,  the  patient  will  then  receive  a 
dose  of  some  3000  in  20  c.c. 

"If  the  serum  be  of  higher  potency,— say,  800  units 
to  the  cubic  centimeter, — the  patient  will  then  have 
received  16,000  units.  For  intrathecal  injections 
this  high  potency  serum,  if  procurable,  should  by  all 
means  be  used.  At  the  same  time  5000  to  10,000 
units  should  be  injected  intramuscularly,  and  3000 
to  5000  may  also  be  given  subcutaneously. 

"The  intrathecal  injections  may  be  repeated  daily 
for  three  to  five  days,  when  they  should,  as  a  rule, 
be  discontinued.  The  intramuscular  and  subcuta- 


84  TREATMENT  OF  WAR  WOUNDS 

neous  injections  may  be  continued  daily  or  oftener, 
according  to  the  severity  of  the  symptoms.  When 
the  disease  shows  distinct  signs  of  abating,  the  size 
of  the  dose  may  be  gradually  decreased,  the  interval 
between  the  doses  lengthened,  and  the  serum  given 
only  subcutaneously.  .  .  .  .  . 

"2.  Symptomatic. — Symptomatic  treatment  con- 
sists in  the  exhibition  of  sedative  drugs.  Perhaps 
the  most  suitable  is  morphin  in  \£  grain  doses,  ad- 
ministered every  four  hours;  potassium  bromid, 
chloral,  chloretone,  paraldehyd,  are  also  given  by 
the  mouth  or  rectum. 

"Carbolic  Acid. — There  is  no  convincing  evidence 
that  the  carbolic  acid  treatment  of  tetanus  has  any 
curative  effect  whatever  or  any  action  upon  the 
course  of  the  disease. 

"Magnesium  Sulphate. — Treatment  by  sulphate 
of  magnesium  has  no  effect  upon  the  disease  itself. 
The  cessation  of  spasm  which  follows  an  injection  is 
only  temporary,  and  is  purchased  at  the  cost  of  risks 
which  are  far  more  negligible.  It  is  very  doubtful 
if  any  real  advantage  is  gained  by  its  use. 

"Surgical  Treatment  of  the  Wound. — There  is  a  gen- 
eral impression  that  it  is  of  advantage  to  excise  the 
wound  or  amputate  the  limb  in  cases  of  tetanus.  The 
matter  is  one  upon  which  there  is  considerable  differ- 
ence of  opinion.  From  the  clinical  experience  of 
many  observers  it  would  seem  that  these  procedures 
are  of  little  avail,  and  may  actually  accelerate  the 
course  of  the  disease.  Animal  experiment,  so  far  as 


TETANUS  85 

it  goes,  also  suggests  that  operative  measures  are 
useless. 

"While  more  evidence  is  required  before  any  dog- 
matic statement  can  be  made,  it  appears  safer  to 
abstain  from  surgical  interference  with  the  wound 
until  the  ordinary  treatment  for  tetanus  has  been 
carried  out,  unless  there  exist  other  and  imperative 
reasons  for  immediate  operation. 

"The  irrigation  of  the  wound  with  oxidizing  agents, 
such  as  hydrogen  peroxid,  when  this  can  be  done 
without  undue  disturbance  and  without  opening  up 
the  wound,  is  to  be  recommended. 

"Reporting  and  Care  of  Cases. — In  every  Command 
one  or  more  officers  with  special  knowledge  should 
be  detailed  ...  to  visit  and  assist  in  treatment 
of  cases  of  tetanus.  These  officers  should  be  at  the 
general  hospitals  of  the  district,  and  their  names  and 
telephonic  addresses  should  be  communicated  to  the 
officers  and  medical  practitioners  in  charge  of  sub- 
sidiary hospitals. 

"On  occurrence  of  a  case  of  tetanus  the  appointed 
officer  will  be  immediately  informed,  and  he  will  at 
once  proceed  to  visit  the  case  and  offer  assistance  in 
the  carrying  out  of  such  treatment  as  has  been  sug- 
gested in  the  present  memorandum.  He  will,  if 
necessary,  assist  in  the  operation  of  lumbar  puncture 
and  intrathecal  injection.  This  will  seldom  be  neces- 
sary, as  from  what  has  already  been  said  as  to  the 
danger  of  even  an  hour's  delay  this  intrathecal  in- 
jection will  usually  have  been  done  before  his  arrival, 


86  TREATMENT  OF  WAR  WOUNDS 

unless  the  distance  to  be  traveled  is  short.  He  will 
make  careful  inquiry  into  the  case  in  order  to  ascer- 
tain if  any  early  symptoms  had  been  present  and 
had  escaped  notice.  He  will  note  what  prophylactic 
injections  had  been  made,  and  if  omitted,  why  they 
were  omitted.  When  visiting  the  hospital  where  the 
case  has  occurred,  he  will  ascertain  if  the  other 
wounded  men  are  receiving  prophylactic  injections. 
He  should  see  that  sufficient  notes  of  the  case  are 
being  kept  in  order  that  the  tetanus  form  can  be 
filled  up  as  fully  as  possible.  For  example,  it  is  very 
seldom  that  the  distinguishing  marks  on  the  bottles 
of  serum  are  reported.  If  serum  trouble  arises,  it  is 
evident  that  this  information  would  be  useful.  He 
will  forward  an  inspector's  report  to  Surgeon-General 
Sir  David  Bruce  with  as  little  delay  as  possible. 
The  ordinary  tetanus  report  will  be  filled  in  by  the 
medical  officer  in  charge  of  the  case.  [In  the  United 
States  Army  this  report  would  go  to  the  surgeon's 
immediately  superior  officer  unless  other  special 
orders  had  been  issued.] 

"Officers  in  charge  of  hospitals  will  be  responsible 
for  the  administration  of  the  second  and  following 
prophylactic  doses  of  antitoxin  to  all  wounded  under 
their  care  unless  reasons  exist  for  withholding  them. 
The  administration  of  antitoxin  will  be  recorded  on 
the  case-sheet.  They  will  also,  as  heretofore,  inform 
Surgeon-General  Sir  David  Bruce,  by  telegram,  of 
the  occurrence  of  a  case  of  tetanus,  and  on  the  death 


TETANUS  87 

or  recovery  of  the  case,  forward  the  usual  tetanus  re- 
port in  accordance  with  War  Office  instructions. 

"Any  abnormalities  of  behavior  of  anti tetanic 
serum  should  be  carefully  noted  and  reported. 

"As  the  Tetanus  Committee  was  appointed  for  the 
purpose  of  studying  tetanus,  it  is  greatly  to  be  de- 
sired that  every  medical  officer  will  cooperate  in  a 
collective  investigation,  and  submit  any  evidence  in 
his  possession  which  may  add  to  our  knowledge  of 
the  disease  and  its  treatment. 

"WAR  OFFICE,  S.  W.,  October  25,  1916." 

APPENDIX 
The  Method  of  Performing  an  Intrathecal  Injection 

"The  patient  should  preferably  be  under  general 
anesthesia,  but  the  operation  can  be  performed  with 
local  anesthesia.  The  skin  over  the  area  of  the  fourth 
and  fifth  lumbar  spines  should  be  painted  with  iodin 
or  cleansed  with  soap  and  water,  followed  by  an  anti- 
septic. A  spinal  needle  and  20  c.c.  syringe  should  be 
boiled  in  normal  saline,  and  the  surgeon  must  observe 
throughout  the  most  rigorous  aseptic  precautions. 

"The  patient  is  bent  head  to  knees,  so  as  to  pre- 
sent as  fully  a  curved  back  to  the  operator  as  possi- 
ble, and  the  position  of  the  fourth  lumbar  spine 
ascertained  by  drawing  an  imaginary  line  between 
the  crests  of  the  ilia. 

"The  tip  of  the  finger  is  placed  on  the  supraspinous 
ligament  connecting  the  summits  of  the  spinous  proc- 
esses of  the  fourth  and  fifth  lumbar  vertebrae.  The 


88  TREATMENT  OF  WAR  WOUNDS 

needle  is  inserted  about  three-eighths  of  an  inch  to 
one  side  of  the  middle  line,  and  directed  forward  and 
slightly  upward  and  inward.  If  the  needle  strikes 
the  bone,  it  should  be  withdrawn  and  a  fresh  attempt 
made.  The  canal  is  reached  at  a  depth,  on  an  aver- 
age, of  about  2^2  inches  (5  cm.).  The  trocar  is  with- 
drawn, and  about  20  c.c.  of  cerebrospinal  fluid  al- 
lowed to  flow  out  into  a  measured  vessel.  The  syringe 
is  then  fitted  to  the  needle  and  the  serum  injected. 

"It  is  important  that  the  serum  be  heated  to  the 
temperature  of  the  body  and  the  injection  made  very 
slowrly. 

"The  canal  can  also  be  reached  by  pushing  the 
needle  through  the  supraspinous  ligament  in  the  mid- 
dle line,  half-way  between  the  two  spinous  processes. 

"If  several  injections  have  to  be  made,  it  is  well 
to  choose  fresh  sites. 

"Blocking  of  the  flow  of  the  cerebrospinal  fluid  by 
a  blood-clot  may  be  overcome  by  reinserting  and 
withdrawing  the  trocar. 

"The  bed  should  be  tilted  at  the  foot  and  the  pil- 
low removed  for  an  hour  or  two  after  the  injections." 


GAS  INFECTION  AND  GAS  GANGRENE 

The  difference  between  these  two  conditions  should 
be  noticed. 

Gas  infection  is  very  common  in  the  wounded  in 
the  present  war.  As  Bowlby  notes,  it  is  practically 
unknown  in  Great  Britain.  The  same  is  true  in  the 
United  States.  Personally  I  never  saw  a  single  case 
in  the  Civil  War,  and  but  one  case  in  civil  life  since 
then.  In  the  present  war  Taylor  notes  the  presence 
of  the  gas  bacillus  of  Welch  in  70  per  cent,  of  the 
cases.  Fleming*  found  it  in  103  wounds  out  of  127, 
and  in  the  clothing  in  10  out  of  12  cases.  Fortunately 
the  infection  can  be  controlled  with  much  success  if 
it  be  seen  and  treated  early. 

Gas  gangrene,  on  the  contrary,  is  a  result  of  pro- 
gressively developed  infection  and  is  a  most  dangerous 
condition. 

The  cause  is  most  commonly  the  bacillus  of  Welch 
— B.  aerogenes  capsulatus,  often  called  B.  perfringens 
by  the  French.  Other  gas-producing  bacteria  are 
also  found. 

*  Lancet,  September  18,  1915,  p.  638. 
89 


90  TREATMENT  OF  WAR  WOUNDS 

The  rapidity  of  the  growth  of  the  bacillus  of  Welch, 
and  therefore  the  urgent  need  of  instant  and  radical 
action,  is  best  appreciated  by  Kenneth  Taylor's 
method  of  obtaining  a  pure  culture:*  A  series  of  six 
or  more  culture-tubes  are  inoculated,  each  tube 
from  its  predecessor,  at  intervals  of  only  half  an  hour. 
Even  in  this  short  interval  bubbles  of  gas  become  evi- 
dent in  the  successive  tubes.  By  the  sixth  or  seventh 
tube  one  may  obtain  a  pure  culture,  so  far  has  the 
gas  bacillus  outgrown  all  other  germs.  The  bacteri- 
ologist and  the  surgeon  should  always  cooperate. 

Tissier's  observations!  are  illuminating.  Working 
on  wounds  in  the  present  war,  and  by  animal  experi- 
mentation, he  has  shown  the  following  noteworthy 
facts:  Filtered  cultures  of  the  Welch  bacillus  and  of 
that  of  malignant  edema  were  inert.  Unfiltered  cul- 
tures were  followed  by  only  a  hard  edema,  which 
gradually  disappeared.  If,  however,  there  were  added 
to  the  Welch  bacillus  aerobic  cultures,  e.  g.,  of  the 
enterococcus,  then  a  guinea-pig  would  be  killed  in 
three  days ;  if  it  were  the  staphylococcus  albus,  death 
followed  in  twenty-four  hours;  if  the  streptococcus 
was  added,  death  followed  in  fifteen  hours.  This 

*  "  Pathol.  and  Bact.  of  Gas  Gangrene,"  Jour.  Path,  and  Bact., 
1916,  xx,  384. 

f  Ann.  Institut.  Pasteur,  December,  1916. 


GAS  INFECTION  AND  GAS  GANGRENE          91 

marked  difference  he  attributes  to  the  restraint  on  the 
anaerobes  by  the  oxygen  in  the  circulating  blood. 
The  observation  of  Bowlby  that  he  has  never  seen 
gas  gangrene  in  the  head,  and  almost  never  in  the 
neck,  affords  strong  support  to  this  view,  as  their 
blood-supply  is  far  more  abundant  than  that  of  any 
other  part  of  the  body.  The  addition  of  the  aerobes 
removes  this  restraint.  The  latter,  so  to  speak,  pre- 
pare the  soil  and  allow  the  anaerobes  then  to  play 
their  destructive  role.  For  the  first  six  to  eight  hours 
the  wounds  contain  few  bacteria;  by  the  tenth  hour 
the  anaerobes  begin  to  multiply  rapidly;  by  twelve 
hours  they  are  the  dominant  growth. 

Clinically  also  the  same  astonishingly  rapid  devel- 
opment is  seen.  Bowlby*  has  observed  well-marked 
infection  with  formation  of  gas  within  five  hours, 
and  death  from  gas  gangrene  of  an  entire  limb  in 
sixteen  hours. 

All  foreign  bodies  (clothing,  etc.)  in  the  wound,  as 
they  will  keep  up  the  anaerobic  infection,  must  be  re- 
moved; all  dead  tissue  must  be  removed,  the  wounds 
kept  open,  and  frequent  antiseptic  dressings  used. 
My  own  impression  is  that  Dakin's  fluid,  Taylor's 
quinin  chlorhydrate,  and  possibly  some  other  anti- 
septics, when  properly  used  in  connection  with  the 
*  Brit.  Jour.  Surg.,  1915-16,  151. 


92  TREATMENT  OF  WAR  WOUNDS 

above  absolutely  necessary  means,  will  enable  the 
surgeon  to  conquer  the  infection  at  the  start,  if  he 
sees  the  patient  as  early  as  possible — certainly  within 
the  first  twenty-four  hours.  If  the  infection  has 
gained  headway  and  gas  production  has  already  set 
in,  then  the  treatment  by  incisions  and  all  means  to 
facilitate  the  escape  of  the  gas,  and  nothing  which 
will  hinder  it,  with  further  removal  of  dead  tissue 
and  the  continued  use  of  the  chosen  antiseptic,  espe- 
cially by  Carrel's  method,  in  many  cases  will  result 
in  cure;  if  gas  gangrene  has  actually  occurred,  cer- 
tainly if  it  is  extensive,  then  immediate  amputation 
will  be  needful  in  many,  if  not  in  most,  cases. 

While  the  blood  often  contains  the  gas,  the  bacillus 
itself  is  not  often  found  in  the  blood.  It  is  chiefly 
a  saprophytic  bacillus,  the  gas  being  produced  by 
the  destruction  especially  of  the  muscular  tissue,  ac- 
cumulating at  first  in  between  the  muscular  bundles. 
A  detached  arm  or  leg  will  sometimes  float  in  water 
because  of  the  great  quantity  of  gas  in  it.  In 
the  intramuscular  spaces  it  quickly  compresses  the 
muscular  tissues  mechanically  until  it  bursts  the 
sheath.  Meantime  necrosis  of  the  tissue  occurs,  and 
a  severe  toxemia  may  easily  follow — not  from  the  gas 
itself,  since  Taylor  believes  he  has  shown  that  the 
bacillus  itself  is  not  toxic,  but  from  the  toxic  products 
of  the  necrotic  muscles. 


GAS  INFECTION  AND  GAS  GANGRENE          93 

Treatment. — The  paramount  importance  of  the 
earliest  possible  treatment  during  the  first  stage  of 
rapidly  spreading  infection,  before  the  production  of 
gas  in  any  serious  quantity  has  occurred,  is  self- 
evident.  Every  hour  counts  against  the  patient. 

Taylor*  points  out  clearly  what  is  to  be  done : 

1.  Destruction  of  the  bacillus. 

2.  Removal  of  the  tissue   especially  favoring  its 
growth,  i.  e.,  the  necrotic  muscles. 

3.  Measures  to  prevent  the  destruction  of  the  mus- 
cles as  a  result  of  mechanical  pressure. 

For  the  destruction  of  the  bacilli  Taylor  recom- 
mends a  one  per  cent,  solution  of  chlorhydrate  of 
quinin.  Others  have  found  Dakin's  fluid  effective. 

Bowlby  (see  his  letter,  p.  131)  has  noted  the  almost 
entire  absence  of  gas  gangrene  in  the  head  and  neck. 
This  he  attributes  to  the  unusually  large  blood-sup- 
ply carrying  a  large  amount  of  oxygen.  As  the  bacil- 
lus of  Welch  is  an  anaerobe,  oxygen  is  inimical  to 
its  growth.  Depage  has  used  injections  of  oxygen 
into  the  tissues  infected  with  the  Welch  bacillus 
with  advantage — probably  for  the  same  reason. 

The  muscles  should  be  explored  by  numerous  longi- 

*  "La  Gangrene  Gazeuse,"  Arch,  de  Med.  et  de  Pharmacie 
Militaire,  1916;  Lancet,  September  4,  1915,  538,  and  January 
15,  1916,  123;  Brit.  Med.  Jour.,  December  25,  1915,  923. 


94  TREATMENT  OF  WAR  WOUNDS 

tudinal  incisions,  incisions  of  the  muscular  sheaths, 
and  the  excision  of  all  necrosed  tissue.  Sometimes 
single  muscles  or  a  group  of  muscles  may  need  to  be 
excised.  The  dead  muscle  can  be  distinguished  from 
the  living  by  its  dirty  brick-red  color,  in  contrast  to 
the  normal  purple-brown.  The  dead  muscles  also 
lose  their  contractility.  The  focus  of  infection,  if 
known,  should  be  excised.  The  wound  should  be 
dressed  with  the  chosen  antiseptic  solution.  The  in- 
cisions should  be  kept  open  by  light  gauze  compresses 
wet  with  this  solution.  No  circular  bandages  which 
can  exert  the  least  compression,  and  so  hinder  the 
escape  of  the  gas,  are  allowable.  Nothing  should  ob- 
struct the  free  escape  of  the  gas.  Everything  should 
promote  it. 

If  gas  gangrene  occurs  or  has  already  set  in,  the 
same  free  incision  should  be  made,  unless  this  has  al- 
ready been  done. 

Bacteriologic  diagnosis  in  the  early  stage  is  most 
important.  Soon  the  discoloration  of  the  skin,  blebs, 
and  crepitation  make  the  diagnosis  positive,  but  crepi- 
tation often  appears  late  rather  than  early.  The 
x-ray  may  disclose  the  bubbles  of  gas  in  the  tissues. 
On  incision,  if  the  muscular  tissue  is  bloodless,  pale, 
dry,  of  a  brick-red  color,  gangrene  already  exists. 
The  best  judgment  then  will  be  required  to  decide 


ANTITOXIN  AGAINST  GAS  GANGRENE         95 

whether  free  excision  of  this  gangrenous  tissue,  with 
suitable  subsequent  dressing,  or  immediate  ampu- 
tation should  be  done.  If  the  limb  is  amputated, 
it  should  be  by  the  so-called  "guillotine"  method, 
i.  e.,  without  flaps.  The  wound  should  be  dressed 
with  the  end  of  the  stump  entirely  uncovered  until 
the  infection  has  been  conquered.  Then  the  skin 
may  be  drawn  down  by  lacing  or  by  weights  and 
sutured  as  soon  as  feasible.  The  bone  may  have  to 
be  shortened. 

AN  ANTITOXIN  TO  PREVENT  GAS  GANGRENE 

One  of  the  most  important  contributions  to  surgery 
as  a  result  of  the  war  has  appeared  just  as  I  am  cor- 
recting the  proof  of  this  Report,  in  a  paper  by  Carroll 
G.  Bull  and  Miss  Ida  W.  Pritchett,  of  the  Rockefeller 
Institute.*  It  greatly  extends,  in  fact  may  be  said  to 
revolutionize,  our  knowledge  of  the  pathology  of  gas 
gangrene  and  its  cause,  and,  what  is  still  more  impor- 
tant and  cheering,  has  given  us  the  promise  of  an 
antitoxin  which  it  seems  not  too  much  to  expect  will 
be  as  potent  for  the  prevention  of  gas  gangrene  as  the 
antitetanic,  antityphoid,  and  other  similar  antitoxins 
are  in  preventing  these  latter  maladies. 

Experiments  on  animals,  by  using  four  strains  of 
*  Jour.  Exp.  Med.,  July,  1917. 


96  TREATMENT  OF  WAR  WOUNDS 

the  B.  Welchii  from  wounds  in  the  European  War 
and  one  from  the  lining  of  an  old  overcoat  at  home, 
have  led  to  "the  discovery  of  the  conditions  under 
which  a  highly  potent,  soluble  toxic  agent  is  regularly 
produced  by  the  bacilli,  on  which  their  poisonous  or 
lethal  action  chiefly  if  not  wholly  depends." 

This  powerful  soluble  toxin  sometimes  killed  ani- 
mals in  from  a  few  hours  to  a  few  minutes,  and  even 
almost  instantly. 

"The  cause  of  death  in  Bacillus  Welchii  infection 
is  not  a  blood  invasion  of  the  microorganisms  and 
not  acid  intoxication,  but  an  intoxication  with  definite 
and  very  potent  poisons  produced  in  the  growth  of 
the  bacilli  in  the  tissues  of  the  body.  .  .  ." 

"The  poison  or  toxin  is  a  complex  of  an  hemolysin 
and  another  poisonous  body.  The  latter  is  the  more 
toxic,  since  it  may  bring  about  death  under  conditions 
in  which  no  blood  destruction  takes  place. 

"The  experiments  briefly  reported  .  .  .  seem 
to  possess  considerable  importance.  They  indicate, 
indeed,  that  in  Bacillus  Welchii  infection  in  nature 
the  development  of  the  spores  into  vegetative  bacilli 
may  be  prevented  by  a  protective  inoculation  of  an 
antitoxic  serum,  and  also  that  the  vegetative  bacilli 
may  be  deprived  by  such  a  serum  of  their  toxic  prod- 
ucts, which  now  appear  to  be  their  real  offensive  in- 
strument. We  are  confronted,  therefore,  not  only 
with  a  new  point  of  view  regarding  the  manner  of 


ANTITOXIN  AGAINST  GAS  GANGRENE          97 

the  pathogenic  action  of  the  Welch  group  of  bacilli, 
but  also  with  a  new  means  of  combating  their  patho- 
genic effects. 

'The  experiments  presented  appear  to  admit  of 
one  interpretation  only;  namely,  that  the  Welch 
bacilli,  under  suitable  conditions  of  growth,  produce 
an  active  exotoxin,  to  which  their  pathogenic  effects 
are  ascribable.  The  toxic  product,  moreover,  acts 
upon  the  local  tissues  and  the  blood  in  a  manner 
identical  with  the  action  of  the  cultures.  With  the 
toxic  product  animals  may  be  immunized  actively 
and  an  immune  serum  which  neutralizes  the  toxin  per- 
fectly and  in  multiple  proportion  be  secured.  The 
toxic  bodies  would  seem  to  be  at  least  two  in  number: 
one  causing  blood  destruction,  hence  an  hemolysin, 
and  the  other  acting  locally  on  the  tissues  and  blood- 
vessels, causing  edema  and  necrosis  and  probably 
exerting  general  toxic  action  in  addition." 

These  views  differ  greatly  from  those  current  up 
to  the  present  time.  To  me  they  seem  to  be  based 
on  ample  experiments  and  on  sound  reasoning.  Dr. 
Welch  himself  has  expressed  his  approval  of  the  con- 
clusions. Some  of  the  antitoxin  I  understand  has 
already  been  sent  to  the  surgeons  in  the  field.  The 
results  of  their  tests  on  the  wounded  will  be  awaited 
with  the  deepest  interest,  and  it  is  to  be  hoped  will  be 
conclusively  favorable.  Doubtless  time  will  also  bring 


98  TREATMENT  OF  WAR  WOUNDS 

improvements  in  the  method  as  a  result  of  actual  use 
of  the  antitoxin. 

Makins,  on  page  794  of  his  paper  (loc.  cit.),  makes 
an  interesting  reference  to  "Hospital  Gangrene,"  of 
which,  in  common  with  all  our  surgeons,  I  saw  so 
much  during  our  Civil  War.  His  description  would 
apply  fairly  well  to  those  cases,  though  the  rapidly 
spreading  destruction  seen  in  our  Civil  War  cases 
is  not  emphasized  by  Makins.  Since  then  hospital 
gangrene  has  entirely  disappeared.  We  do  not  even 
know  its  pathology  or  its  bacteriology.  Makins 
says: 

"One  form  of  streptococcus  infection  deserves 
special  mention  as  possibly  corresponding  to  the  va- 
riety of  'classical  hospital  gangrene'  described  as 
the  membranous.  Cases  of  this  nature  have  not  been 
common,  although  sufficiently  so  to  have  become 
familiar.  A  wound  which  has  previously  been  appa- 
rently progressing  favourably  becomes  covered  with 
a  dense  grey  tough  membrane,  firmly  adherent  to  the 
subjacent  granulations.  In  the  earliest  stage  this 
membrane  does  not  materially  differ  from  the  thin 
layer  of  coagulated  fibrin  and  included  leucocytes 
which  not  uncommonly  forms  in  cases  of  strepto- 
coccic  infection  which  after  a  time  fail  to  respond  to 
treatment.  The  same  cessation  of  free  discharge  from 
the  wound  surface  is  observed,  a  condition  well  de- 


HOSPITAL  GANGRENE  99 

scribed  by  Colonel  Sir  Almroth  Wright  as  'lymph 
bound.'  The  membrane  then  thickens  so  as  to  re- 
semble one  of  the  diphtheritic  class;  in  fact,  strong 
suspicion  was  aroused  in  the  earlier  stages  of  the  war 
that  the  change  was  due  to  a  diphtheritic  infection. 
Bacteriological  examination  has,  however,  in  all  cases 
resulted  in  the  discovery  of  streptococci  alone." 
.  .  .  "Amputation  is  usually  followed  by  a  re- 
currence of  the  same  type  of  wound  surface,  and  the 
patient  dies  in  from  four  days  to  a  week's  time  after 
the  commencement  of  the  process.  No  successful 
method  of  dealing  with  this  special  form  of  wound 
infection  has  been  devised." 

Our  treatment  during  the  Civil  War  was  empirical 
but  was  bacteriologically  correct.  The  patient  being 
almost  always  etherized,  the  whole  wound  was  cauter- 
ized by  nitric  or  nitro-muriatic  acid,  the  acid  nitrate 
of  mercury,  pure  bromin,  or  the  actual  cautery.  This 
effectually  sterilized  the  wound.  When  the  slough 
separated,  it  was  treated  as  any  other  fresh  wound. 


WOUNDS  OF  THE  HEAD 

In  spite  of  steel  helmets,  wounds  of  the  head  are 
exceedingly  numerous.  This  is  owing  to  the  uni- 
versal use  of  trench  warfare  and  on  a  scale  hitherto 
unknown.  While  many  of  these  cases  find  their  way 
into  the  hospitals,  a  still  larger  number  die  even 
before  they  can  be  collected  or  sent  to  a  hospital. 

"One  of  the  lessons  which  has  been  taught  us," 
as  Gushing  has  well  pointed  out,  is  that  "judgment 
comes  only  from  special  experiences."  Two  of  the 
best  illustrations  of  the  value  of  experience  are  seen 
in  the  Surgery  of  the  Head  and  the  Surgery  of  the 
Jaws:  "Only  experts  can  make  50  per  cent,  of  lac- 
erated faces  and  jaws  capable  again  of  army  crusts." 

Among  the  communications  in  the  journals  dealing 
with  cranial  wounds,  one  of  the  most  judicious,  as 
one  would  naturally  expect,  is  that  by  Dr.  Harvey 
Gushing.*  His  "conclusions"  seem  to  me  to  be  so 
excellent  that  I  quote  them  in  full : 

"There  is  a  fairly  universal  agreement  that  almost 
all  cranial  wounds  produced  by  projectiles,  even 

*  Military  Surgeon,  June- July,  1915. 
100 


WOUNDS  OF  THE  HEAD  101 

though  they  appear  trivial,  require  surgical  investi- 
gation, with  the  possible  exception — (1)  of  certain 
of  the  tangential  longitudinal  sinus  injuries,  which, 
according  to  Sargent  and  Holmes,  have  a  high  degree 
of  spontaneous  recoverability,  and  which,  when  in- 
vestigated, present  unusual  surgical  risks;  and  (2) 
of  certain  of  the  fractures  of  the  base  due  to  perforat- 
ing wounds,  owing  to  their  inaccessibility. 

"There  is,  however,  a  wide  divergence  of  opinion 
as  to  when  and  where  these  operations  should  be  per- 
formed. It  is  recognized  that  cases  treated  immedi- 
ately at  a  field  ambulance  appear  to  do  well  for  a 
time,  but  are  apt  to  suffer  from  complications  after 
their  evacuation.  These  complications  are  often 
ascribed  to  the  patient's  transportation,  whereas 
they  are  due,  in  greater  probability,  to  the  fact  that 
these  early  interventions  of  necessity  are  hurriedly 
undertaken  and  imperfectly  executed,  and  that  the 
wounded  must  oftentimes  be  evacuated  at  about  the 
time  when  complications  from  sepsis  are  likely  to 
occur. 

"With  the  exception  of  the  more  serious  injuries 
with  extensive  hemorrhage,  in  which  surgical  mea- 
sures are  practically  unavailing,  craniocerebral 
wounds,  as  a  rule,  present  no  immediate  urgency, 
for  as  a  tissue  the  brain  is  notably  tolerant  of  con- 
tusions and  infections.  Hence  a  delay  of  two  or 
three  days  in  forwarding  this  class  of  wounded  with 
expedition  to  a  suitable  base  is  preferable  to  the  de- 
lay of  two  or  three  days  in  having  them  recover  from 


102  TREATMENT  OF  WAR  WOUNDS 

the  effects  of  an  incomplete  procedure  before  trans- 
portation. 

"  One  can  rarely  tell,  from  the  external  appearance 
of  these  wounds,  how  serious  a  matter  the  intra- 
cranial  exploration  will  prove  to  be,  and  if  the  pro- 
cedure is  abandoned  after  a  trifling  crucial  incision 
with  a  possible  trepanation  and  the  removal  of  a 
few  fragments  of  bone  and  clot,  followed  by  a  gauze 
pack,  a  herniation,  fungus,  and  infection  will  often 
ensue. 

"Even  apparently  trivial  scalp  wounds  may  in  the 
end  require  extensive  and  elaborate  operations,  which 
demand  a  thorough  neurologic  study,  fluoroscopy,  or 
#-ray  plates,  a  carefully  planned  and  deliberate  inter- 
vention under  skilful  anesthesia,  and  the  aid  of  such 
accessories  for  the  extraction  of  certain  types  of 
missiles  as  an  electromagnet.  Accurate  closure  of 
the  operative  wound  is  desirable,  and  direct  drain- 
age, particularly  by  gauze,  of  the  area  of  denuded 
cortex  should  be  avoided  if  possible.  The  success  of 
such  a  procedure  is  greatly  handicapped  by  earlier 
direct  enlargements  of  the  original  wound." 

Especially  do  I  indorse,  on  general  principles,  his 
advice  that  the  only  proper  hospital  to  interfere 
surgically  with  a  cranial  wound  is  one  in  which  fa- 
cilities in  skilled  men,  both  neurologic  and  surgical, 
and  the  best  #-ray  apparatus  are  to  be  had.  I  am 
told  that  at  present  (May,  1917)  some  hospitals, 


WOUNDS  OF  THE  HEAD  103 

much  nearer  to  the  trenches  than  formerly,  are  thus 
equipped.  An  incompletely  studied  case  and  an  in- 
different facility  for  diagnosis  and  operation  have  no 
place  in  cranial  wounds.  The  late  results  of  such 
surgery  are  lamentable. 

Gutter  wounds  may  comminute  the  skull  and  pro- 
duce serious  intracranial  lesions.  These,  as  Gushing 
points  out,  have  been  often  incompletely  operated 
on  at  busy  first-line  hospitals  and  passed  on  with 
gauze  packing,  thus  inviting  infection. 

For  hemorrhage  he  advises  Horsley's  suggestion, 
viz.,  the  implantation  of  raw  muscle  often  to  be  ob- 
tained from  the  flap  itself. 

The  wound  should  be  most  carefully  cleansed  and 
the  edges  resected.  The  opening  in  the  bone  should 
be  freely  exposed  by  a  large  flap  and  the  opening  en- 
larged sufficiently  for  inspection  and  such  operative 
measures  as  are  deemed  necessary. 

The  dura  should  not  be  opened  save  to  evacuate 
blood-clots  or  evidently  disorganized  brain  tissue, 
to  tie  bleeding  vessels,  or  for  a  formal  decompression. 
In  these  always  violently  infected  wounds  this  is  of 
especial  importance.  I  cannot  subscribe  to  Burck- 
hardt's  statement*  as  to  the  innocuousness  of  such 
incisions.  It  is  best  to  close  the  dura  and  the  over- 
*  Brims'  Kriegschir.,  Heft  19,  p.  618. 


104  TREATMENT  OF  WAR  WOUNDS 

lying  galea  and  scalp  immediately  to  avoid  a  fungus 
cerebri.  Efficient  drainage  should  be  provided.  For 
this  purpose  rubber  tissue  is  far  better  than  gauze. 

Decompression  operations  may  relieve  increased 
intracranial  pressure.  Sargent  and  Holmes*  have 
used  with  advantage  contralateral  decompression. 
This  has  the  great  advantage  of  being  done  in  clean 
tissue.  If,  however,  the  decompression  is  done  on 
the  same  side  as  the  wound,  then  to  protect  the  brain 
from  the  infected  scalp  flap  they  recommend  that 
the  scalp  be  widely  loosened  from  the  skull,  and  that 
one  or  two  pedunculated  flaps  of  pericranium  be  slid 
over  the  brain  and  carefully  sutured  in  place,  followed 
by  closure  of  the  scalp  wound. 

In  operations  on  cranial  wounds,  when  possible, 
access  should  be  had  through  an  independent  clean 
incision  rather  than  by  enlarging  the  almost  cer- 
tainly infected  original  wound.  Foreign  bodies  in  the 
brain  should  be  extracted  as  soon  as  a  complete  opera- 
tion can  be  done,  for  in  this  war  practically  all  such 
foreign  bodies  are  infected.  But  the  surgeon  must 
use  his  good  judgment  and  not  venture  beyond  the 
limits  of  reasonably  legitimate  surgery.  Sometimes 
a  secondary  operation  at  a  much  later  date  will  be 
best.  Between  the  danger  of  infection  and  the  danger 
*  Brit.  Med.  Jour.,  March  27  and  November  30,  1915. 


WOUNDS  OF  THE  HEAD  105 

of  operation  only  a  large  experience  and  good  judg- 
ment can  decide.  Occasionally  a  powerful  electro- 
magnet may  remove  a  missile,  provided  it  is  of  a 
metal  which  is  amenable  to  such  treatment.  The 
vibrations  caused  by  an  intermittent  current  may 
aid  in  loosening  the  foreign  body.  The  value  of  the 
#-ray,  especially  in  the  present  improved  forms,  is 
insisted  on. 

Bowlby*  recommends  permanent  special  hospitals 
for  such  cases.  These  have  been  developed  by  the 
British  as  a  result  of  experience,  by  which  we  should 
profit.  Whether  a  case  can  bear  immediate  transpor- 
tation is  decided  largely  by  the  pulse.  If  it  be  rapid, 
the  patient  should  not  be  forwarded  at  once.  A  slow 
pulse  favors  the  presumption  of  possible  recovery. 
Such  patients,  as  a  rule,  will  bear  transportation  last- 
ing even  for  two  or  three  days.  Moreover,  an  imme- 
diate operation  at  or  near  the  front  is  not  only  apt 
to  be  an  incomplete  operation,  but  is  often  followed 
by  a  great  drop  in  the  blood-pressure.  A  moderate 
delay  is  a  benefit.  He  summarizes  the  treatment  as 
follows : 

"A  primary  cleansing  of  the  wound.  The  trans- 
mission of  the  patient  as  soon  as  possible  to  the  hospi- 
tal, where  he  will  convalesce.  The  taking  of  x-ray 

*  Brit.  Med.  Jour.,  June  2,  1917. 


106  TREATMENT  OF  WAR  WOUNDS 

pictures.  The  excision  of  the  scalp  and  bone  wound. 
A  limited  and  careful  removal  of  foreign  bodies.  The 
covering  of  the  exposed  brain.  The  closure  of  the 
wound,  with  superficial  drainage,  and  a  prolonged 
rest  in  bed." 

These  views  are  reinforced  also  by  Makins,*  who 
says: 

"Examination  of  a  considerable  number  of  pa- 
tients some  months  after  their  return  to  England 
proved  much  more  satisfactory  than  had  been  gener- 
ally expected.  It  was  found  that  the  proportion  of 
patients  who  die  after  transference  to  England  is 
small;  later  complications,  such  as  cerebral  abscess, 
are  comparatively  rare,  and  serious  sequelae,  such  as 
insanity  and  epilepsy,  are  much  less  common  than 
had  been  foretold.  In  only  15  per  cent,  of  the  pa- 
tients examined,  however,  had  more  than  one  year 
elapsed  from  the  date  of  the  injury.  It  also  appeared 
that  many  patients  with  foreign  bodies  deeply  lodged 
in  the  brain  recover,  and  are  scarcely  more  liable  to 
serious  complications  than  men  in  whom  the  brain 
has  been  merely  exposed  and  lacerated.  These  con- 
clusions are  obviously  tentative,  but  as  far  as  they 
go  appear  hopeful." 

Sargent  (in  Bowlby's  paper),  from  a  very  large  ex- 
perience, confirms  the  same: 

"The   very   large   experience   gained   of   gunshot 
*  Brit.  Med.  Jour.,  June  16,  1917. 


WOUNDS  OF  THE  HEAD  107 

wounds  of  the  head  has  led  to  a  considerable  degree 
of  modification  in  their  treatment.  Immediate  rou- 
tine operation,  often  incomplete,  and,  in  the  absence 
of  full  neurological  information  and  x-ray  examina- 
tion, sometimes  unnecessary  and  even  misdirected,  is 
no  longer  widely  practised.  It  has  long  since  been 
made  abundantly  clear  that  early  evacuation  of  oper- 
ated cases  is  often  followed  by  disaster.  As  it  is  im- 
possible to  operate  upon  these  cases  and  to  retain 
them  at  the  clearing  stations  for  a  period  which  ren- 
ders transportation  safe,  more  especially  during  times 
of  great  military  activity,  the  practice  now  generally 
adopted  is  to  transfer  them  without  operation  as  soon 
as  possible  to  hospitals  further  down  the  line.  It  has 
been  made  quite  clear  that  surgical  intervention  is 
rarely  required  for  the  relief  of  cerebral  symptoms, 
whether  general  or  focal.  Its  chief  aim  is  the  preven- 
tion of  intradural  infection.  On  this  conception  all 
cases  of  gunshot  wounds  of  the  head  fall  into  one  of 
two  categories,  according  to  whether  the  dura  mater 
has  or  has  not  been  penetrated.  Non-penetrating 
wounds  have  a  low  rate  of  mortality,  whether  oper- 
ated upon  or  not,  provided  that  the  surgeon  respects 
the  integrity  of  the  dura  mater. 

"It  is  customary,  therefore,  to  do  in  these  cases 
only  as  much  as  may  seem  advisable  to  ensure  speedy 
healing,  such  as  excision  of  the  edges  of  the  wound, 
removal  where  necessary  of  bony  fragments,  and  par- 
tial or  complete  closure  of  the  gap  in  the  scalp  either 
by  suture  or  by  some  form  of  plastic  operation." 


108  TREATMENT  OF  WAR  WOUNDS 

Penetrating  wounds  should  be  treated  conserva- 
tively, as  indicated  by  Bowlby. 

As  to  retained  missiles,  Sargent  says: 

"Removal  of  bullets,  even  when  the  wounds  have 
healed  and  the  risk  of  septic  infection  thereby  is 
largely  diminished,  must  be,  even  in  skilled  hands, 
attended  by  an  amount  of  damage  which,  in  most 
cases,  would  have  more  serious  neurological  conse- 
quences than  could  the  presence  of  an  aseptic  bullet. 

"Primary  removal  of  a  deeply  seated  missile  car- 
ries with  it  the  additional  risk  of  septic  infection. 
For  these  reasons  the  usual  practice  is  to  leave  alone 
such  missiles." 

This  corresponds  to  what  I  often  stated  to  my  stu- 
dents and  always  acted  on  to  advantage.  "If  the 
surgeon,  by  seeking  to  extract  a  missile  retained  in 
the  brain,  will  do  more  harm  then  the  missile,  do  not 
operate" — and  vice  versa. 

Holmes  and  Sargent,*  after  a  study  of  over  70 
cases,  have  described  "The  Longitudinal  Sinus  Syn- 
drome." The  paper  cannot  well  be  summarized,  but 
their  conclusions  as  to  treatment  are  concise  and  rea- 
sonable. As  a  rule,  do  not  operate.  If  operation  be 
done,  secure  ample  access  to  control  the  almost  cer- 

*  "Injuries  of  the  Superior  Longitudinal  Sinus,"  Jour.  Royal 
Army  Med.  Corps,  1915,  xxv,  p.  56. 


WOUNDS  OF  THE  HEAD  109 

tain  serious  hemorrhage  which  can  often  be  controlled 
by  Horsley's  method. 

Makins  rightly  calls  attention  to  a  valuable  paper 
by  Lister  and  Gordon  Holmes  entitled  "Distur- 
bances of  Vision  from  Cerebral  Lesions,  with  Especial 
Reference  to  the  Cerebral  Representation  of  the 
Macula."*  It  is  fully  illustrated  and  is  a  most  impor- 
tant contribution  both  to  cerebral  localization  and  to 
the  physiology  of  vision.  It  is  particularly  creditable 
that  men  so  constantly  overworked  should  persis- 
tently continue  their  scientific  researches. 

*  Proc.  Roy.  Soc.  Med.,  1916,  ix,  Section  on  Ophthalmology, 
p.  57. 


WOUNDS  OF  THE  CHEST 

Herringham*  bases  an  excellent  paper  on  211  cases. 
The  conclusions  are  much  the  same  as  one  reaches 
in  civil  surgery.  If  the  patient  is  profoundly  col- 
lapsed, as  is  naturally  more  often  the  case  than  in 
civil  life,  on  account  of  the  wholly  different  condi- 
tions, the  heart-beat  may  not  even  be  perceptible. 
Rest  for  a  day  with  heat  and  morphin  in  suitable 
doses  will  often  bring  about  great  improvement. 

An  open  external  wound,  allowing  the  free  flow  of 
the  air  in  and  out,  causes  generally  a  very  distressing 
dyspnea.  Hence  if  it  is  small  it  should  be  closed  by 
strapping. 

If  it  is  larger  and  therefore  practically  certain  to 
become  infected  if  left  so,  remove  any  loose  bone, 
round  off  the  edges  and  the  ends  of  the  bones,  and  if 
possible  close  the  wound  by  drawing  the  muscles  and 
skin  over  it.  If  it  cannot  be  entirely  closed,  a  drain 
may  have  to  be  inserted.  Herringham  then  recom- 
mends filling  the  cavity  with  an  antiseptic. 

More  or  less  intrathoracic  hemorrhage  is  the  rule  in 

*  Brit.  Med.  Jour.,  June  2,  1917. 
110 


WOUNDS  OF  THE  CHEST  111 

wounds  of  the  chest.  If  the  effusion  does  not  rise 
above  the  middle  of  the  scapula  nor  in  front  of  the 
midaxillary  line,  it  does  not  cause  much  distress. 
Happily  this  represents  the  majority  of  wounds  of  the 
chest.  "Watchful  waiting"  then  should  be  the  rule. 
After  seventy-two  hours  there  is  little  danger  of  fur- 
ther hemorrhage;  if  need  be,  such  cases  may  then  be 
evacuated  without  serious  danger. 

If  the  effusion  increases  so  as  to  displace  the  heart 
and  the  pulse  rises  to  over  100  and  the  respiration  to 
over  32,  the  chest  should  be  aspirated,  and  according 
to  what  is  found  the  patient  may  be  evacuated  or  a 
formal  operation  be  done,  by  rib-resection,  with  free 
drainage. 

If  the  z-ray  shows  a  foreign  body  in  the  chest  when 
the  patient  first  comes  under  observation  after  being 
wounded,  on  the  succeeding  day,  or  even  the  same  day, 
if  his  condition  allows,  this  should  be  removed  and  the 
wound  entirely  closed  after  disinfection.  In  a  mod- 
erate percentage  such  cases  make  a  speedy  recovery. 


WOUNDS  OF  THE  JOINTS 

The  military  surgery  of  joints  is,  par  excellence,  that 
of  the  knee.  Bowlby's  remarks  on  these  injuries*  are 
well  worth  quoting  in  part: 

"A  great  change  for  the  better  has  taken  place  in 
the  results  obtained  in  the  treatment  of  wounded 
joints.  .  .  . 

"Experience  was  chiefly  gained  on  the  knee-joint, 
for  it  is  the  joint  most  frequently  hit,  most  easy  of 
inspection,  and  its  infection  is  followed  by  disastrous 
consequences  more  often  than  in  the  case  of  other 
articulations.  .  .  . 

'The  first  improvement  was  the  abandonment  of 
the  intra-articular  drains.  The  next  was  the  excision 
of  the  wound,  the  removal  of  any  foreign  body,  the 
flushing  of  the  joint,  and  in  some  cases  the  closure 
of  the  capsule  and  the  insertion  of  a  superficial 
drain.  .  .  . 

"The  next  step  was  perhaps  a  bold  one.  As  soon 
as  possible  after  the  receipt  of  the  injury — that  is, 
in  the  casualty  clearing  station — the  wound  was  ex- 
cised, the  joint  opened,  cleaned,  and  irrigated,  and 
then  the  whole  wound  in  the  synovial  sac  and  the 

*  Brit.  Med.  Jour.,  June  2,  1917. 
112 


WOUNDS  OF  THE  JOINTS  113 

superficial  tissues  was  tightly  closed.  It  was  certainly 
astonishing  how  seldom  infection  followed  such  treat- 
ment, even  when  fragments  of  shell  or  pieces  of  cloth- 
ing had  been  removed  from  the  joint;  but  for  its 
success  it  is  essential  that  the  incisions  around  the 
wound  edges  should  be  carried  quite  clear  of  all  in- 
fected tissue,  and  that  the  strictest  asepsis  is  assured. 

"  Now,  every  knee-joint  with  such  a  wound  is  given 
the  chance  of  healing  by  first  intention,  although  the 
closure  of  the  joint  defect  may  entail  the  performance 
of  a  plastic  operation  to  provide  an  adequate  cover 
with  a  flap  of  synovial  membrane  or  skin.  Even  if 
some  infection  does  follow  the  closure  of  the  joint, 
it  is  well  not  to  be  in  too  great  hurry  to  lay  the  artic- 
ulation open,  for  a  certain  number  of  such  joints  do 
settle  down  and  provide  a  better  limb  than  if  sub- 
mitted to  more  active  treatment. 

"When  the  joint  wound  is  complicated  with  frac- 
ture of  bone  it  may  still  be  possible  in  some  cases  to 
close  it  with  success.  In  cases  of  compound  fracture 
of  the  patella  with  loss  of  substance,  partial  or  com- 
plete removal  of  the  fragments,  and  the  provision  of 
a  skin  flap,  will  often  be  followed  by  primary  healing. 

"When  the  tibia  or  femur  is  involved  the  case 
becomes  more  serious.  Of  the  two  fractures,  that  of 
the  tibia  is  the  most  to  be  feared." 

The  "bold  step"  of  primary  closure  of  the  joint  is 
clearly  justified  by  the  following  statistics  from  a 
table  including  845  cases  of  injury  to  the  knee-joint 

8 


114  TREATMENT  OF  WAR  WOUNDS 

at  the  Rouen  hospital,  quoted  from  Barling  by 
Makins,*  a  part  of  which  I  reproduce,  is  very  impress- 
ing. The  contrast  as  to  re-operation  between  the  cases 
of  excision  and  closure,  and  excision  and  packing,  is 
most  instructive. 

1.  Total  cases  of  injury  to  knee  operated 

on 845 

2.  With  bone  injury 438 

3.  Without  bone  injury 407 

4.  WTound  excised  and  closed 322 

5.  Cases  with  wounds  excised  and  closed 

requiring  further  operation 82  =  25.5  per  cent. 

6.  Wound  excised  and  packed 33.6 

7.  Cases  with  wounds  excised  and  packed 

requiring  further  operation 128  =  38.4  per  cent. 

*  Brit.  Med.  Jour.,  June  16,  1917. 


ABDOMINAL  WOUNDS 

The  experience  of  the  Boer  War  led  us  toward  ab- 
stention in  abdominal  wounds  unless  there  was  sus- 
pected hemorrhage  or  fair  evidence  of  visceral  lesion. 
This  was  due  to  the  small  jacketed  bullet,  which 
not  seldom  traversed  the  abdominal  cavity  without 
wounding  any  viscera. 

In  this  war,  especially  of  late,  the  bomb,  grenade, 
and  high  explosive  shell  have  changed  all  this. 
Rarely,  in  case  of  penetration,  do  the  viscera  escape. 
Hence  the  burden  of  proof  has  been  shifted.  Ab- 
dominal section  is  now  the  rule  unless  there  is  good 
reason  to  believe  that  the  viscera  have  not  been 
wounded. 

Wallace  and  Hughes  and  Rees*  give  encouraging 
statistics  as  to  operative  interference  in  abdominal 
wounds,  showing  a  reduction  in  mortality  of  some  10 
per  cent,  at  the  front.  The  importance  of  the  earliest 
possible  operation  is  emphasized  especially  by  the 
figures  of  the  last  two  surgeons.  Patients  operated 
on  within  the  first  six  hours  (43  in  number)  showed  a 

*  Lancet,  April  28,  1917. 
115 


116  TREATMENT  OF  WAR  WOUNDS 

recovery  percentage  of  62.8  per  cent.  In  those 
operated  on  between  six  and  twelve  hours  (33  cases) 
this  had  fallen  to  36.3  per  cent.  In  operations  done 
between  twelve  and  sixteen  hours  (18  cases)  it  had 
fallen  to  16.6  per  cent.  After  over  twenty -four 
hours  (11  cases)  the  recovery  rate  rose  to  45.4  per 
cent.  This  can  be  readily  accounted  for  on  the 
ground  that  the  more  seriously  wounded  had  al- 
ready succumbed  before  reaching  the  hospital. 

A  good  illustration  of  how  a  hospital  may  be  sud- 
denly flooded  with  operative  cases  is  given  by  Lock- 
wood  and  his  colleagues.*  After  being  rushed  with 
the  wounded  from  four  days  of  continuous  active 
fighting,  suddenly  in  one  night,  between  9  and  12 
o'clock,  96  operative  cases — one  every  two  minutes- 
were  received.  Of  these,  36  were  abdominal  cases, 
and  of  these,  32  were  operated  on.  One  significant 
statement  is  that  the  surgeon  "was  usually  obliged 
to  operate  alone." 

Not  uncommonly  the  missile  reaches  the  abdomen 
through  the  back  and  the  buttock,  as  well  as  from  the 
front. 

It  is  very  often  a  question  whether  operation 
should  be  done  at  once  after  the  patient  has  been 

*  Lockwood,  McGill,  Kennedy,  MacFie,  and  Charles:  Brit. 
Med.  Jour.,  March  10,  1917. 


ABDOMINAL  WOUNDS  117 

transported  over  a  rough  road,  and  it  may  well  be 
in  marked  shock  and,  in  the  cold  weather,  chilled 
through.  Of  course,  if  there  is  evident  hemorrhage, 
or  a  strong  suspicion  of  it,  immediate  operation  must 
be  done.  The  usual  restoratives,  and  if  possible  the 
measures  advocated  by  Porter  (vide  p.  14),  may  be 
resorted  to  if  the  patient's  condition  requires  them. 
Lockwood  and  his  colleagues  base  their  decision 
chiefly  on  the  pulse.  If  this  is  above  120  beats,  opera- 
tion should  be  deferred  for  a  reasonable  time  for  re- 
action to  set  in.  All  foreign  bodies  must  be  removed 
at  whatever  cost.  If  left  behind,  it  is  practically  a 
sentence  of  death. 

Both  Lockwood  and  his  colleagues  and  Fraser  and 
Drummond,  in  the  same  issue  of  the  Journal,  note  that 
there  may  be  a  flaccid  abdomen  instead  of  rigidity. 
This  is  seen  also  in  civil  life,  especially  when  shock 
and  intestinal  hemorrhage  combine  to  exhaust  the 
patient  and  before  protective  muscular  rigidity  has 
set  in  as  a  result  of  beginning  peritonitis. 

The  small  intestine  may  exhibit  multiple  wounds, 
not  only  as  in  civil  life,  by  multiple  perforations  from 
a  single  missile,  but  in  this  war  especially  from  multi- 
ple missiles  from  exploded  shell  or  shrapnel,  to  say 
nothing  of  additional  wounds  elsewhere  in  the  body 
(cf.  p.  30).  One  excellent  piece  of  advice  is  given 


118  TREATMENT  OF  WAR  WOUNDS 

by  Fraser  and  Drummond:  First,  determine  how 
many  wounds  of  the  intestine  there  are,  their  extent 
and  locality,  before  deciding  on  the  proper  treatment. 
Then  identify  the  cecum  and  then  trace  the  small 
intestine  from  there  upward.  "As  each  perforation 
of  the  gut  is  exposed  it  is  wrapped  up  in  a  small 
moist  swab."  The  tape  attached  to  the  swab  "is 
slipped  through  the  mesentery  and  doubled  twice 
around  the  gut."  This  avoids  escape  of  the  con- 
tents and  additional  infection,  and  gives  one  at  a 
glance  the  means  of  judging  what  should  be  done. 
Special  care  should  be  taken  not  to  overlook  wounds 
of  the  posterior  wall  of  the  stomach  and  of  the  colon. 

Since  Crile  has  preached  the  "gospel  of  gentle- 
ness," no  good  surgeon  will  handle  bowel  or  other 
viscera  roughly  or  expose  more  than  a  foot  or  two  at 
a  time,  nor  dally  with  his  operation.  Speed,  but  never 
haste,  is  the  rule.  This  is  especially  necessary  when 
scores  of  cases  may  be  urgently  needing  surgical 
relief. 

As  a  rule,  wounds  susceptible  to  suture  should 
be  so  treated  even  when  there  are  several  of  them. 
Not  seldom,  however,  a  serious  question  will  arise 
whether  suture  or  resection  should  be  resorted  to. 
Most  civil  surgeons,  I  think,  much  prefer  to  avoid 
resection  if  possible.  The  authors  of  both  the  papers 


ABDOMINAL  WOUNDS  119 

just  referred  to — in  all,  six  authors,  who  between 
them  had  treated  800  abdominal  wounds,  an  excep- 
tional experience,  which  entitles  their  final  judgment 
to  special  weight — are  decidedly  of  the  same  opin- 
ion. Fraser  and  Drummond  go  so  far  as  to  say  that 
the  only  condition  warranting  resection  is  extensive 
damage  to  the  mesentery  or  extravasation  between 
the  two  layers  of  the  mesentery  at  its  attachment  to 
the  bowel  where  the  latter  is  partially  not  covered 
by  the  peritoneum. 

Their  reason  is  the  profound  shock  which  attends 
resection  and  which  may  easily  turn  the  scale  against 
the  patient.  Too  many  of  us,  in  civil  life,  at  least,  do 
not  give  sufficient  weight  to  this  reason. 

If  resection  has  to  be  done,  Lockwood  and  his 
colleagues  prefer  end-to-end  suture;  Fraser  and 
Drummond,  and  Bowlby  prefer  lateral  anastomosis, 
so  as  to  avoid  distention  of  the  proximal  segment  in 
end-to-end  anastomosis.  The  latter  do  not  seem  to 
have  tried  what  Lockwood  and  his  associates  recom- 
mend— before  closing  the  abdomen,  to  milk  the  gut 
gently  "from  ju§t  above  the  distended  area  to  just 
below  the  sutured  area."  Post-operative  paralysis  of 
the  bowel  and  distention,  they  assert,"  practically  never 
occurred"  when  this  simple  precaution  was  taken. 

Lacerated  kidneys  may  recover  if  not  too  widely 


120  TREATMENT  OF  WAR  WOUNDS 

injured.  In  these  cases  extensive  experience  and 
sound  judgment  are  invaluable.  Immediate  neph- 
rectomy  is  to  be  avoided,  if  possible,  and  to  be  re- 
sorted to  (if  then  necessary)  when  the  patient  is  in 
better  condition. 

Irrigation  and  drainage  are  not  commonly  em- 
ployed. Fraser  and  Drummond,  however,  particularly 
urge  drainage  in  wounds  of  the  colon,  and  especially 
posterior  drainage,  to  avoid  retrocolic  infection.  Ob- 
vious infection  elsewhere  may  also  require  drainage. 

The  Fowler  position  is  desirable  as  soon  as  possible 
after  the  operation.  If  need  be,  drainage  of  the  pelvis 
may  be  employed,  but  not  probably  for  over  twenty- 
four  or  thirty-six  hours. 

Sometimes  morphin — which  I  have  already  com- 
mended as  an  initial  measure  for  the  relief  of  severe 
pain — is  given  in  larger  doses  than  is  wise.  This 
complicates  recovery,  especially  by  masking  intra- 
abdominal  symptoms. 

According  to  Bowlby,*  an  operative  recovery  of  50 
per  cent,  in  present  conditions  is  the  best  that  one 
can  expect — a  great  contrast  to  civil  surgery!  Hem- 
orrhage is  the  principal  cause  of  this  deplorable  result. 
Hence  again  the  need  for  quick  transportation  and 
prompt  operation  except  in  such  deep  shock  as  to 
*  Brit.  Med.  Jour.,  June  2,  1917. 


ABDOMINAL  WOUNDS  121 

forbid  operation  until  reaction  has  been  attained.  If 
salines  are  to  be  used,  it  should  be  by  intravenous 
infusion,  for  in  deep  shock  little  if  any  absorption 
takes  place  if  it  be  given  subcutaneously.  But  if 
hemorrhage  is  the  probable  cause  of  the  shock,  then 
operation  to  control  it  is  the  only  possible  hope.  The 
pulse  is  of  the  greatest  importance.  Of  145  cases 
with  a  pulse  over  120,  only  16  recovered — a  mortality 
of  over  89  per  cent.  After  thirty-six  hours  operation 
is  evidently  unnecessary,  as  a  rule. 

Bowlby  gives  the  following  table  of  results  in  1038 
cases  treated  during  eighteen  months: 

Considered  with  view  to  operation ....  1038 

No  operation  advised 73 

Total  operations 965 

Total  operative  mortality 53.9  per  cent. 

Total  hollow  viscera  mortality 64.7 

Stomach  mortality* 52.7 

Small  gut  mortality* 65.8 

Colon  mortality* 58.7 

*  Uncomplicated  by  wound  of  other  hollow  alimentary  vis- 
cus. 


BURNS 

These  are  much  more  frequent  in  this  war  than 
heretofore.  Dr.  Barthe  de  Sandfort  greatly  improved 
on  the  old  paraffin  dressings  by  a  preparation  which 
he  named  Ambrine,  from  the  oil  of  amber  mixed  with 
the  paraffin.  I  have  seen  a  number  of  photographs 
of  his  cases,  and  have  no  doubt  as  to  the  value  of  the 
treatment.  Unfortunately,  in  absolute  contraven- 
tion of  American  medical  ethics,  he  has  kept  the 
exact  formula  and  the  method  of  preparing  it  secret, 
and  it  can  be  obtained  only  from  him  or  from  the 
commercial  company  in  Paris  to  whom  he  has 
divulged  the  secret. 

Lieut.-Col.  A.  J.  Hull,  of  the  British  Army,*  after 
a  series  of  experiments,  has  obtained  a  preparation 
which  experience  has  shown  to  be  superior  to  Am- 
brine. He  calls  it  "No.  7  Paraffin."  The  formula  is 
as  follows: 

Resorcin 1  per  cent. 

Eucalyptus  oil 2 

Olive  oil 5 

Paraffin  molle 25 

Paraffin  durum 67 

*  Brit.  Med.  Jour.,  January  13,  1917,  p.  37. 
122 


BURNS  123 

The  resorcin  may  be  diminished  to  25  per  cent. 
If  resorcin  is  difficult  to  obtain,  the  formula  may  be 
changed  to  the  following: 

Beta-naphthol 0.25  per  cent. 

Eucalyptus 2.00 

Olive  oil 5.00 

Paraffin  molle 25.00 

Paraffin  durum 67.75 

The  method  of  application  is  as  follows:  Wash 
the  burn  with  sterile  water.  Dry  it  by  fanning  or 
by  laying  dry  gauze  on  the  surface.  The  paraffin 
mixture  is  then  applied  by  a  spray  or  by  a  broad 
camel's-hair  brush,  sterilized  in  wax  and  used  very 
gently.  This  preparation  has  a  melting-point  of 
48°  C.  (118.4°  R).  It  should  be  heated  to  50°  C. 
(122°  R),  but  this  temperature  can  be  roughly  "esti- 
mated by  waiting  till  the  wax  shows  a  solidifying 
film  on  the  surface." 

"A  thin  layer  of  cotton- wool,  cut  the  same  size  as 
the  area  of  the  burn,  is  placed  over  the  wound  after 
the  first  layer  of  paraffin  has  been  applied.  This 
layer  of  wool  is  covered  with  a  second  layer  of  para- 
ffin. The  wool  is  cut  in  thin  sheets  and  pressed  be- 
tween layers  of  paper  in  order  to  obtain  thin  layers 
of  wool.  The  dressing  is  completed  by  applying  wool 
bandage.  The  burns  are  usually  dressed  daily  (or 
later  every  second  day).  .  .  . 


124  TREATMENT  OF  WAR  WOUNDS 

"Blisters  are  not  interfered  with  in  any  way  at  the 
first  dressing;  the  paraffin  is  applied  after  washing 
the  burn.  At  the  second  dressing  the  dead  layers  of 
skin  are  cut  away." 

This  paraffin  preparation  has  been  employed  to 
advantage  also  in  "trench  feet." 

In  the  British  Medical  Journal  of  April  28,  1917, 
p.  549,  is  a  further  statement  in  reference  to  the  para- 
ffin treatment  of  burns.  This  shows  also  the  ato- 
mizer which  is  used  in  spraying  it  over  the  wound. 

In  the  Journal  of  the  American  Medical  Associa- 
tion for  May  19,  1917,  pp.  1497-1500,  is  a  very  full 
explanation  of  the  origin  and  composition  of  Ambrine 
and  the  various  paraffin  preparations  by  Paul  N. 
Leech,  Ph.D. 

In  the  Journal  of  the  American  Medical  Association 
for  June  16,  1917,  are  two  valuable  articles  by  Soll- 
mann  and  Beiter  on  the  Paraffin  Treatment  of  Burns 
which  advance  our  knowledge  considerably.  Beiter 
especially  has  had  a  large  experience  in  the  treat- 
ment of  burns  in  industrial  works.  Their  conclusions 
are  that  the  application  of  the  ordinary  melted  par- 
affin to  the  wound  is  much  too  painful.  They  rec- 
ommend, after  cleansing,  that  the  first  application 
shall  be  the  "Petrolatum  Liquidum"  (known  com- 
mercially as  " Stanolind  Liquid  Paraffin"),  which  can 


BURNS  125 

be  sprayed  on  the  burn  by  the  ordinary  oil  atomizer, 
or  can  be  applied  on  a  cotton  swab.  This  is  entirely 
painless.  Then  the  cotton  film  is  applied  and  the 
melted  paraffin  painted  over  it,  etc.,  as  usual. 

Beiter  says  that  "superficial  burns  heal  more 
quickly  by  this  treatment,  but  that  when  the  tissues 
are  destroyed  in  deep  burns  and  scar  tissue  results, 
the  scar  tissue  performs  as  scar  tissue  has  performed 
since  the  beginning  of  time."  Sir  Anthony  Bowlby, 
on  the  contrary,  declares  that  the  scars  are  "soft  and 
supple  and  there  is  a  marked  absence  of  bad  con- 
tractures."  Others  also  have  noted  this  advantage. 

In  the  issue  of  the  same  journal  for  June  23,  1917, 
in  order  to  melt  and  keep  liquid  the  paraffin,  Soll- 
mann  advises,  when  available,  an  electrical  "food 
warmer,"  or  better  an  ordinary  glue-pot  (size  0), 
containing  something  over  a  pound  of  sodium  ace- 
tate. In  this  pot  a  smaller  one,  containing  about  a 
pound  of  paraffin,  is  placed.  When  the  sodium  acetate 
is  melted  at  a  temperature  of  59°  C.  (138.2°  F.)  it  will 
remain  at  an  ideally  usable  temperature  for  two  hours 
and  be  still  usable  for  another  hour.  It  can  be  re- 
heated again  and  again. 


SOME  PERSONAL  LETTERS* 
LETTER  FROM  DR.  JOSEPH  A.  BLAKE 

Chief  Surgeon  of  the  Hospital  V.  R.  76,  Ris-Orangis,  France 

November  22,  1916. 

"I  have  received  your  letter  of  October  26th  in 
which  you  request  my  views  in  regard  to  'new  dis- 
coveries and  their  application  in  the  treatment  of 
wounds  in  the  present  war.' 

"It  would  require  a  book  to  reply  satisfactorily 
to  this  question  if  all  the  methods  of  wound  treat- 
ment were  considered  and  recognition  given  to  what 
their  authors  claim  for  them.  I  am  not  ready  as  yet 
to  give  a  definite  opinion  in  regard  to  any  of  them. 

"In  this  hospital,  with  the  help  of  Dr.  Kenneth 
Taylor,  the  head  of  our  Research  Laboratory,  I 
have  been  studying  and  making  comparisons  be- 
tween several  of  these  methods,  and  I  am  sending 
you  a  few  reprints  which  may  interest  you.  One  is 
in  connection  with  Sir  Almroth  Wright's  method, 
which  method,  in  our  experience,  is  of  no  particular 
value. 

*  These  letters  from  men  actually  in  the  war  were  written  at 
my  request  for  incorporation  in  this  Report. 

126 


DR.  JOSEPH  A.  BLAKE'S  LETTER  127 

"In  regard  to  the  Dakin  solution  and  Dakin's 
chloramin-T,  we  are  now  trying  to  determine  what 
the  reactions  in  the  wounds  are  of  the  hypochlorite 
solution.  It  is  possible  that  an  amin  is  formed  in 
connection  with  the  wound  secretions.  We  are  hav- 
ing good  results  with  the  Dakin  fluid,  using  Carrel's 
method  of  instillation,  but  are  having  equally  good 
results  from  other  antiseptics  employed  in  the  same 
way.  For  instance,  in  cases  of  B.  aerogenes  capsu- 
latus  infections,  we  are  using  a  solution  of  quinin, 
and  in  pyocyaneus  infections  we  are  using  a  weak 
solution  of  acetic  acid  or  a  combination  of  acetic 
acid  and  cresol,  we  having  found  that  an  acid  solu- 
tion is  necessary  to  control  the  B.  pyocyaneus.  It 
grows  freely  in  wounds  treated  with  Dakin's  solution. 

"In  general,  I  am  inclined  to  believe  that  there  is 
no  antiseptic  which  fulfils  all  indications,  and  that 
the  successful  treatment  of  wounds  depends  largely 
upon  the  skill  of  the  surgeon  in  preparing  them  for 
treatment  and  in  dressing  them  afterward. 

"In  regard  to  the  treatment  of  gas  gangrene,  I 
think  the  reprints  which  I  am  sending  you  will  suffi- 
ciently explain  the  reasons  for  what  I  regard  to  be 
the  best  treatment,  i.  e.,  free  incisions  through  apon- 
euroses  and  fascia  surrounding  the  muscles,  and  the 
separation  of  the  muscles  infected  by  blunt  dissec- 


128  TREATMENT  OF  WAR  WOUNDS 

tion  with  the  fingers,  the  idea  being  to  prevent  the 
creation  of  subfascial  pressure  upon  the  muscles  by 
contained  gas  and  exudate. 

"I  am  sending  you  a  reprint  of  a  splint  for  trans- 
portation of  fractures  of  the  lower  extremity. 

"In  regard  to  feeding,  housing,  etc.,  I  can  say 
nothing  except  that  it  should  be  the  best  obtainable. 
Of  course,  all  this  depends  upon  the  facilities  at  hand 
and  the  rush  of  wounded.  For  instance,  a  hospital 
of  300  beds,  in  ordinary  conditions  of  trench  wrarfare, 
could  easily  find  transport,  food,  and  care  for  all  the 
cases  coming  to  it,  but  at  any  time  might  be  swamped 
by  a  thousand  cases  in  one  day.  .  .  . 

LETTER  FROM  SIR  ANTHONY  A.  BOWLBY,  BART. 

General  Headquarters,  British  Annies  in  France 

[Penciled  notes  based  on  an  enormous  number  of  cases,  written  on  foolscap,  and 
evidently  amid  many  difficulties. — W.  W.  K.] 

"Until  our  Somme  Battle  quieted  down  I  was 
living  in  a  tent  on  the  Ancre  and  not  anxious  to  write 
more  letters  than  I  could  help. 

"I  now  send  you  some  brief  notes  in  reply  to  your 
inquiries.  .  .  . 

"We  had  a  busy  time,  but  we  had  anticipated 
and  prepared  for  it,  so  all  went  very  wrell  and  the 
wounded  were  all  well  looked  after. 


SIR  ANTHONY  A.  BOWLBY'S  LETTER  129 

"I  have  been  much  struck  by  the  excellence  of 
very  many  young  surgeons,  for  we  have  now  at  the 
front  a  really  fine  operating  staff,  and  they  have  saved 
many  thousands  of  lives  by  their  skill  and  by  very 
hard  work.  This  has  been  a  very  encouraging  feature 
amidst  many  sad  sights,  for  the  mutilations  by  shells 
are  really  horrible." 

"  The  treatment  of  wounds  which  today  finds  most 
favor  is  that  known  as  Carrel's.  This  may  be  briefly 
summarized  as  excision  of  any  recently  wounded  or 
dirty  tissue  and  the  subsequent  irrigation  of  the 
wound  by  frequent  instillation  of  'Dakin's  fluid.' 
In  the  British  army  the  preparation  known  as  '  Eusol ' 
is  often  used  instead  of  Dakin's  fluid,  from  which  it 
does  not  materially  differ. 

"Wounds  already  suppurating  are  not  treated  by 
excision. 

'Hypertonic  Saline'  [of  Sir  Almroth  Wright]  has 
been  recently  used  very  little  at  the  front,  as  most 
surgeons  consider  that  the  hypochlorous  acid  solu- 
tions give  better  results.  I  hear  that  it  is  also  not 
much  used  at  the  base  hospitals,  and  personally,  I 
have  never  seen  any  of  the  advantages  claimed  for  it 
and  have  never  advised  its  adoption. 

"Various  other  antiseptics  are  used,  such  as  car- 


130  TREATMENT  OF  WAR  WOUNDS 

bolic  acid,  peroxid  of  hydrogen,  etc.,  and  a  combina- 
tion of  the  two  named  above  finds  favor  with  some 
surgeons. 

"  Chloramin  has  not  been  used  enough  yet  to  criti- 
cize. The  excision  of  damaged  tissue  in  all  recently 
inflicted  wounds  is  universally  practised  at  the  front 
whenever  possible,  i.  e.,  in  all  wounds  of  a  serious  or 
extensive  nature. 

"Fixation  by  efficient  splints  is  always  considered 
to  be  of  very  great  importance. 

"Gas  gangrene  may  be  caused  by  several  different 
organisms  and  is  commonly  due  to  a  'mixed  in- 
fection.' 

"In  a  great  majority  of  all  lacerated  wounds  gas 
will  develop  if  they  are  left  long  enough  undressed; 
especially  if  the  wounded  man  lies  out  for  a  day  or 
two.  It  is  best  prevented  by  the  treatment  described 
above. 

"In  many  cases  it  is  slight  and  local,  and  easily 
checked  by  free  incision  and  subsequent  drainage. 
The  affected  muscle  sheaths  and  fascia  must  be  widely 
opened  up,  and  if  any  one  or  two  muscles  are  gan- 
grenous, they  must  be  excised. 

"If  a  main  artery  is  injured  and  the  limb  is  af- 
fected by  gas  gangrene,  amputation  is  necessary  at 
once. 


SIR  ANTHONY  A.  BOWLBY'S  LETTER         131 

"In  many  compound  fractures  this  same  treat- 
ment is  required. 

"  It  is  a  noticeable  fact  that,  however  lacerated  the 
face  may  be,  gangrene  never  occurs  in  it  or  in  the 
scalp,  and  hardly  ever  in  the  neck.  I  attribute  this 
to  the  large  blood-supply.  I  have  never  seen  gas 
gangrene  in  any  part  of  the  head. 

"  Gas  and  gaseous  crackling  are  often  felt  far  above 
the  area  of  infection,  and  it  is  a  mistake  to  try  and 
amputate  above  all  gas. 

"Antitoxins  and  vaccines  have  proved  to  be  quite 
useless  up  to  the  present. 

'Ambrine'  is  a  very  good  application  for  burns 
or  for  the  open  sores  (caused  by  frost  or  wet  and 
cold)  which  occur  in  many  cases  of  what  we  call 
'trench  feet.' 

"It  appears  to  be  beneficial  by  reason  of  its  physi- 
cal properties,  and  not  because  of  its  chemical  consti- 
tution. Its  exact  composition  is  not  known. 

"We  use  a  similar  preparation  which  we  compound 
of  (a)  hard  and  (6)  soft  paraffin  and  (c)  olive  oil. 
The  object  is  to  get  a  soft,  greasy  preparation  which 
can  be  taken  off  without  injury  to  the  raw  surface 
and  so  without  pain. 

"The  resulting  scars  are  soft  and  supple,  and  there 
is  a  marked  absence  of  bad  contractures.  Wounds 
also  heal  quickly. 


132  TREATMENT  OF  WAR  WOUNDS 

"Head  Wounds  at  the  Front. — We  avoid  extensive 
operations  and,  with  few  exceptions,  do  not  open  an 
uninjured  dura  mater.  It  is  very  necessary  not  to 
move  patients  for  about  three  weeks  after  operation, 
so  that  special  accommodation  is  required. 

"Chest. — Rest  in  bed  and  small  doses  of  morphin 
for  all  and  no  tapping  of  effusion  for  several  days. 

"Subsequently,  if  there  is  a  large  hemothorax, 
either — (a)  tap;  (6)  tap  and  replace  with  oxygen; 
or  (c)  if  septic,  excise  rib  and  drain.  Most  cases  can 
travel  safely  to  the  base  after  three  or  four  days  in 
bed,  and  operative  treatment  is  generally  done  there." 

[The  general  practice  of  experienced  surgeons  in 
France  is  along  these  conservative  lines,  I  judge. 
Depage  and  Tuffier  have  also  applied  the  Carrel- 
Dakin  method  in  cases  of  empyema  with  much  satis- 
faction. The  various  diverticula  are  traced  by  z-ray 
pictures  of  the  chest  by  the  introduction  of  the 
rubber  tubes  threaded  with  silver  wire.  When  the 
discharge  is  sterile,  the  wound  is  closed. — W.  W.  K.] 

"Abdomen. — Our  general  practice  is  to  operate  if 
the  patient  is  got  in  before  thirty-six  hours,  and  very 
many  are  actually  got  in  within  three  or  four  hours 
after  the  injury. 

"Operations  are  not  done  if  the  wound  is  high  up 
and  there  is  good  reason  to  believe  there  is  no  injury 


DR.  HUGH  CABOT'S  LETTER  133 

to  any  hollow  viscus,  as  evidenced  by  the  absence  of 
all  symptoms  and  the  site  of  the  wound.  (Of  course, 
this  statement  might  require  revision  in  any  single 
case,  but  it  will  give  you  an  idea  of  our  practice.) 

"Our  recovery  rate  for  several  thousand  operations 
is  about  45  per  cent.,  mostly  lives  saved. 

"Place  for  Operations  at  the  Front. — At  the  field 
ambulances  we  only  operate  to — (a)  Stop  bleeding. 
(6)  Amputate  hopelessly  smashed  limbs,  (c)  Dress 
bad  fractures,  etc.,  under  anesthetics.  All  other 
operations  are  done  in  the  'Casualty  Clearing  Sta- 
tions,' of  which  there  are  over  50  spread  behind  our 
whole  front  and  all  accessible  to  road  or  rail.  Pa- 
tients can  be  kept  in  these  in  moderate  numbers  for 
a  week  or  two,  and  can  be  got  into  them  from  the 
field  ambulances  in  about  half -hour  to  one  hour. 

"Anesthetics. — 'Ship way's'  apparatus  for  warm 
ether  vapor  is  very  good.  It  conserves  ether,  and 
there  is  a  complete  absence  of  all  secretions  of  mucus 
and  saliva." 

LETTER  FROM  DR.  HUGH  CABOT 

Boston 

November  21,  1916. 

.     .     .     It  is  not  easy  for  me  to  say  from  any- 
thing more  than  hearsay  evidence  of  conditions  exist- 


134  TREATMENT  OP  WAR  WOUNDS 

ing  in  previous  wars,  precisely  what  is  new  and  what 
is  old.  Clearly  the  experience  of  the  Russo-Japanese 
and  Boer  wars  was  grossly  misleading  in  regard  to 
methods  of  wound  treatment.  In  those  wars  the  ma- 
jority of  wounds  were  caused  by  rifle,  machine-gun, 
and  shrapnel  bullets,  and  those  wars  were  fought 
in  a  comparatively  uncultivated  region.  As  a  result, 
many  wounds  were  practically  uninfected  or  only 
slightly  infected.  First-aid  dressings  promptly  ap- 
plied were  of  great  value  and  conservative  treatment 
gave  good  results. 

"In  this  war  a  large  proportion  of  the  wounds  are 
produced  by  fragments  of  the  shell  casing  of  high 
explosives.  The  wounds  are  lacerated,  quantities  of 
clothing  are  carried  in,  and  as  the  soil  is  for  the  most 
part  that  of  a  highly  fertilized  region,  infections 
with  intestinal  parasites,  such  as  the  Streptococcus 
fsecalis  and  the  Bacillus  aerogenes  capsulatus  of 
Welch,  are  practically  universal.  First-aid  dressings 
have  been  of  very  little  value,  probably  none  beyond 
the  exclusion  of  flies,  thereby  preventing  the  develop- 
ment of  maggots  in  the  wound  where  men  lay  out 
in  shell-holes  for  two  or  three  days.  It  has  not  been 
clear  to  me  that  the  development  of  maggots  was 
an  important  complication,  and  certainly  no  great 
enthusiasm  can  be  evoked  in  regard  to  the  value  of 


DR.  HUGH  CABOT'S  LETTER  135 

first-aid  dressings.  [During  the  Civil  War  I  saw  very 
many  wounds  swarming  with  maggots.  They  were 
very  disgusting,  but  practically  I  do  not  think  they 
did  much  harm.  Cleanliness,  disinfection,  and  pro- 
tection of  the  wounds  from  flies  by  dressings  will  pre- 
vent their  development. — W.  W.  K.] 

"The  experience  of  previous  wars  was  also  wholly 
misleading  in  regard  to  the  treatment  of  abdominal 
wounds.  The  British  surgeons,  going  upon  their  ex- 
perience in  South  Africa,  treated  these  cases  con- 
servatively during  the  first  year,  with  a  mortality  rate 
that  was  nothing  less  than  shocking.  They,  there- 
fore, reversed  their  policy,  established  special  hos- 
pitals as  close  to  the  firing  line  as  possible,  and  have 
carried  out  a  policy  of  operating  upon  all  cases  which 
could  be  brought  to  the  hospital  within  eight  hours 
after  injury.  The  results  in  these  cases  have  shown 
between  40  per  cent,  and  50  per  cent,  of  recoveries — 
an  enormous  improvement  over  the  previous  policy. 

"In  regard  to  tetanus,  it  developed  during  the 
retreat  of  the  early  months  of  the  war  that  wound 
infection  with  tetanus  bacillus  was  almost  the  rule 
and  the  mortality  was  extremely  high.  Since  that 
time  prophylactic  inoculation  given  by  regimental 
medical  officers  as  soon  as  casualties  can  be  reached, 
in  doses  of  from  250  to  750  units,  has  been  brilliantly 


136  TREATMENT  OF  WAR  WOUNDS 

successful.  In  the  hospital  area  with  which  I  was 
associated  this  summer  between  25,000  and  35,000 
casualties  were  received,  and  in  this  number  there 
were  only  ten  cases  of  tetanus,  eight  of  which  died 
and  two  recovered.  My  own  experience  in  about 
8000  casualties  showed  two  cases,  both  of  them  de- 
veloping in  men  who  had  lain  out  for  more  than  two 
days  in  shell-holes,  and  whose  inoculation  was  there- 
fore delayed  [and  infection  with  the  bacillus  was  un- 
hindered.— W.  W.  K.].  One  of  them  died  promptly 
of  acute  tetanus;  the  other  had  the  subacute  type, 
coming  on  after  about  fourteen  days,  and  should 
have  recovered  except  for  accidental  complications.  I 
think,  therefore,  we  may  regard  the  prophylactic 
inoculation  of  antitetanic  serum  as  one  of  the  great 
contributions  to  preventive  medicine  in  war. 

"The  almost  complete  absence  of  typhoid  fever 
must,  I  think,  be  attributed  to  vaccination,  which 
is  now  done  against  three  organisms — the  typhoid 
bacillus,  and  the  alpha  and  beta  paratyphoid.  The 
result  has  been  the  complete  absence  of  typical 
typhoid.  There  are  a  moderate  number  of  cases  of 
unknown  fevers  of  short  duration  which,  on  account 
of  slight  enlargement  of  the  spleen  and  an  occasional 
spot  which  might  be  a  rose  spot,  must  be  classified 
as  possible  typhoid.  Since  all  the  men  show  a  posi- 


DR.  HUGH  CABOT'S  LETTER  137 

tive  Widal  reaction,  diagnosis  by  this  method  is  im- 
possible except  by  methods  altogether  too  laborious 
and  time-consuming  to  be  of  practical  value.  The 
disease,  whether  or  not  it  be  typhoid,  is  trivial  and 
has  been  a  very  unimportant  factor  in  unfitting  men 
for  service.  This,  therefore,  must  also  be  regarded 
as  a  very  important  demonstration  of  the  more  or 
less  generally  accepted  view  that  vaccination  against 
these  conditions,  as  at  present  carried  out,  is  emi- 
nently successful. 

"The  ability  shown  by  the  Royal  Army  Medical 
Corps  to  prevent  diarrheal  diseases,  commonly 
called  dysentery,  in  the  British  Expeditionary  Force 
in  France,  has  been  very  striking.  This,  I  take  it, 
is  the  result  of  their  conscientious  supervision  of 
water-supply  and  their  ability  to  control  the  men. 
In  contrast  to  this  were  the  conditions  existing  in 
Gallipoli,  where  amebic  dysentery  was  a  very  preva- 
lent and  serious  cause  of  disability  and  death.  Up 
to  the  time  of  my  departure  from  France,  about  the 
middle  of  September,  only  a  few  cases  of  amebic 
dysentery  had  occurred  and  it  had  never  been  im- 
portant. 

"In  regard  to  questions  of  transportation  of 
wounded,  the  automobile  ambulances  have  been 
used  as  never  before  and  have  been  able  to  approach 


138  TREATMENT  OF  WAR  WOUNDS 

the  firing-line  pretty  closely.  The  number  of  casual- 
ties resulting  from  the  shelling  of  ambulances  ap- 
pears to  have  been  small,  which,  I  take  it,  means 
that  both  sides  have  avoided  this  practice  where 
possible.  That  it  is  not  always  possible  results  from 
the  fact  that  the  same  road  must  be  used  for  troops 
and  for  ambulances  and  that  combatants  are  there- 
fore justified  in  shelling  the  roads  if  they  think  it 
important  in  preventing  the  bringing  up  of  reen- 
forcements.  The  English  have  established  a  system 
by  which  all  stretchers  and  all  ambulance  bodies  are 
of  a  uniform  type  and  are  therefore  interchangeable. 
For  instance,  in  bringing  a  convoy  to  a  casualty  clear- 
ing station  or  to  a  semi-base  hospital  the  stretchers 
on  which  the  patients  come  are  left  at  the  hospital 
for  the  convenience  of  avoiding  the  shifting  of  pa- 
tients, and  other  stretchers,  precisely  similar,  with  a 
full  complement  of  blankets,  are  picked  up  by  the 
ambulance  as  it  leaves  the  reception  tent. 

"  In  regard  to  splints  for  the  purpose  of  transporta- 
tion, the  extent  to  which  the  so-called  Thomas  knee- 
splint,  with  slight  modifications  to  get  better  exten- 
sion, has  been  applied  to  comminuted  fractures,  both 
of  the  leg  and  arm,  is,  I  think,  a  distinct  advance.  It 
seemed  to  me  altogether  the  most  satisfactory  splint 
for  transportation  purposes,  and  though  giving  some- 


DR.  HUGH  CABOT'S  LETTER  139 

thing  short  of  absolute  fixation,  it  probably  as  nearly 
approaches  this  as  is  practically  possible. 

"Upon  the  question  of  the  treatment  of  infected 
wounds,  I  am  afraid  that  my  observation  will  not 
enable  me  to  indorse  the  very  enthusiastic  views  ex- 
pressed by  some  observers. 

"Infection  with  the  Bacillus  aerogenes  capsulatus 
of  Welch,  also  called  the  Bacillus  perfringens  and  the 
gas  bacillus,  is  enormously  prevalent.  In  my  opinion, 
based  upon  cultures  from  some  200  consecutive  cases, 
it  is  the  active  organism  in  over  80  per  cent.  My 
experience  with  this  infection  covers  considerably 
over  5000  cases  during  three  months,  and  I  was 
enabled  to  see  the  results  of  Sir  Almroth  E.  Wright's 
technic,  since  he  was  at  work  within  fifteen  or  twenty 
miles  of  me.  The  essence  of  his  theory  depends  upon 
the  osmotic  action  of  solutions  of  sodium  chlorid  of 
strengths  up  to  10  per  cent.,  his  thesis  being  that  the 
stronger  solutions  stimulated  serous  discharge  and 
tended  to  remove  a  condition  which  he  describes 
as  lymph-bound.  I  found  that  during  the  summer 
his  views  were  undergoing  considerable  modification, 
that  his  dogmatism  of  June  gave  way  to  much  greater 
catholicity  in  September,  that  he  was  using  more  and 
more  the  weaker  solutions  of  salt  and  nearly  ap- 
proaching the  use  of  a  normal  salt  solution.  As  is 


140  TREATMENT  OF  WAR  WOUNDS 

the  case  with  Carrel  and  Depage,  he  has  a  well- 
equipped  stationary  hospital  with  a  comparatively 
small  number  of  patients  and  a  large  proportion  of 
surgeons,  and  is,  therefore,  in  a  position  to  watch 
his  wounds  enormously  more  closely  than  can  the 
ordinary  field  unit  or  even  semi-base  or  base  hos- 
pitals, and  due  allowance  must  be  made  for  the  very 
great  care  with  which  all  these  gentlemen  supervise 
their  treatment.  I  fear  I  must  conclude  in  regard  to 
Sir  Almroth  E.  Wright's  method  that  it  depends  more 
upon  sound  surgical  principles  and  painstaking  dress- 
ings than  upon  any  peculiarities  of  solutions  em- 
ployed. 

"I  cannot  speak  from  personal  experience  of  Car- 
rel's method,  which,  as  you  know,  consists  of  pretty 
radical  excision  of  damaged  tissue,  irrigation  of  the 
wound  with  a  solution  which  does  not  importantly 
differ  from  Dakin's  solution  or  eusol,  a  careful  bac- 
teriologic  study  of  the  wound,  so  that,  at  a  compara- 
tively early  period, — from  seven  to  ten  days,— 
secondary  suture  can  be  successfully  carried  out. 
That  the  method  as  employed  by  him  at  his  hospital 
has  given  remarkable  results  is  undoubtedly  true. 
On  the  other  hand,  it  requires  an  amount  of  close 
personal  supervision  by  skilled  surgeons  which  is 
quite  impossible  under  real  war  conditions.  He  is 


DR.  HUGH  CABOT'S  LETTER  141 

not,  in  fact,  doing  military  surgery,  and  one  might, 
I  think,  properly  say  of  the  method,  'C'est  mag- 
nifique  mais  ce  n'est  pas  la  guerre.'  [Depage,  with 
800  beds,  almost  at  the  firing-line,  I  think  has  demon- 
strated that  it  is  practicable. — W.  W.  K.]  That 
Carrel's  method  may  be  of  considerable  service  in 
civil  practice  seems  to  me  fairly  demonstrated. 

"In  regard  to  Dakin's  solution,  it  has  all  the  ad- 
vantages of  the  old  chlorinated  soda,  on  which  I  was 
brought  up  and  which  has  since  largely  disappeared. 
On  this  solution  it  is  probably  an  improvement  in 
that  it  is  less  irritating  and  quite  as  efficient.  Its 
deodorizing  properties  are  valuable,  but  I  see  no  rea- 
son to  believe  that  it  has  any  power  to  penetrate 
into  tissues  not  directly  exposed,  and  as  far  as  the 
infection  with  the  gas  bacillus  is  concerned,  exposed 
tissues  are  comparatively  easy  to  deal  with.  My 
own  view  of  the  treatment  of  these  infections  is  as 
follows : 

"Wounds  must  be  laid  widely  open,  and,  as  a  rule, 
transverse  rather  than  longitudinal  incisions  should 
be  employed.  That  such  incisions  are  not  in  fact 
more  destructive  than  the  longitudinal  is  due  to  the 
success  achieved,  as  failure  to  control  the  infection 
results  in  a  tissue  destruction  far  more  serious  than 
that  resulting  from  the  incision.  The  projectile, 


142  TREATMENT  OF  WAR  WOUNDS 

and  particularly  the  clothing  and  foreign  material 
carried  in  ahead  of  it,  must  be  removed,  and  all  pock- 
ets thoroughly  laid  open.  The  forms  of  dressing 
which  tend  to  obstruct  the  wound  must  be  avoided, 
particularly  gauze  packing.  Flow  of  secretions  must 
be  promoted  by  keeping  the  wounds  wet,  and  I  do 
not  believe  that  any  one  solution  has  demonstrated 
any  clear  superiority  in  this  field.  The  use  of  multi- 
ple perforated  tubes  introduced  into  all  portions  of 
the  wound,  through  which  solutions  can  be  intro- 
duced at  frequent  intervals,  is  clearly  an  advance 
in  technic,  but  largely  because  it  avoids  frequent 
changes  of  dressing  and  favors  the  outflow  of  secre- 
tion. That  Dakin's  solution,  eusol,  eupad,  etc.,  are 
popular,  and  that  I  myself  prefer  them,  arises,  I 
think,  more  from  their  deodorizing  qualities  than 
from  any  clearly  demonstrated  antiseptic  action. 
On  the  other  hand,  I  have  a  quite  unconfirmable 
feeling  that  they  probably  have  a  definite  value  as 
antiseptics,  and  are  probably  superior  to  any  other 
antiseptics  with  which  I  am  familiar.  Particularly 
under  conditions  of  active  fighting,  where  the  num- 
ber of  surgeons  is  relatively  small  and  frequent  ex- 
pert dressing  difficult  or  impossible,  salt  solution,  as 
recommended  by  Sir  A.  E.  Wright,  is  likely  to  fail. 
Under  the  reverse  conditions  it  is  at  its  best.  I  have 


DR.  GEORGE  W.  CRILE'S  LETTER  143 

seen  a  group  of  wounds  treated  with  salt  tablets  or 
salt  bags  placed  in  the  deeper  portions  of  the  wound, 
which  is  then  kept  wet  with  normal  saline.  While 
my  experience  is  quite  insufficient  to  form  the  basis 
of  a  scientific  opinion,  I  have  been  impressed  by  the 
extreme  cleanliness  of  these  wounds  and  should  not 
be  surprised  if  it  proved  to  be  one  of  the  discoveries 
of  the  war.  .  .  . 

LETTER  FROM  DR.  GEORGE  W.  CRILE 

Professor  of  Surgery,  Northwestern  University,  Cleveland,  Ohio 

November  4,  1916. 

.  .  .  I  would  like  to  say,  first,  that  the. 
practice  of  giving  large  doses  of  morphin  to  a  seriously 
injured  man  who  is  to  be  transported  is  of  very  great 
importance.  It  protects  him  against  further  shock 
and  the  effects  of  the  loss  of  food  and  drink. 

"I  have  not  been  able  to  form  any  conclusion  as 
to  the  best  method  of  treating  gas  gangrene,  as  all 
methods  have  proved  so  ineffectual.  Of  course,  when 
it  is  to  save  the  life  of  the  patient,  there  is  quick  ampu- 
tation, leaving  the  stump  wide  open,  but  this  will 
lead  to  many  needless  amputations. 

"I  am  satisfied  that  good  results  are  being  obtained 
by  the  use  of  Dakin's  solution  and  by  the  use  of  Sir 
Almroth  Wright's  method.  I  have  had  a  very  con- 


144  TREATMENT  OF  WAR  WOUNDS 

siderable  amount  of  experience  with  Dakin's  solu- 
tion, and  am  convinced  that  it  is  superior  to  bichlorid 
or  to  any  other  antiseptic  we  have  ever  employed. 
I  think  this  will  bear  thorough  investigation.  There 
are  abroad  at  the  present  time  some  contradictory 
reports  regarding  this  method. 

LETTER  FROM  DR.  HARVEY  GUSHING 

Professor  of  Surgery,  Harvard  Medical  School,  Boston,  Mass. 

October  28,  1916. 

.  My  own  experience  was  largely  limited 
to  the  treatment  of  cranial  injuries,  and  it  was  not  a 
particularly  large  one.  I  am  sending  you  a  reprint 
in  which  I  have  stated  my  feelings  in  the  matter. 
.  .  .  Although  the  metal  helmets  have  lessened 
the  number  of  small  penetrating  wounds  which  we 
saw,  there  are,  nevertheless,  of  course,  still  a  great 
number  of  them.  One  thing  that  will  confront  your 
committee,  of  course,  is  the  question  of  protection, 
and  it  looks  as  though  we  were  going  back  by  grada- 
tions to  the  armor  of  the  Middle  Ages.  Another 
very  important  thing  is  protection  against  gas  at- 
tacks, and  I  am  sorry  you  were  not  here  Wednesday 
to  hear  Haldane  speak  on  the  subject,  for  gas  masks 
of  one  type  or  another  will  unquestionably  have  to 
be  prepared  for. 


DR.  HARVEY  CUSHING'S  LETTER  145 

"I  hardly  know  what  to  say  in  answer  to  your  ques- 
tions in  regard  to  the  treatment  of  infection.  Dakin's 
solution  is  being  still  used  with  apparently  very  good 
results,  and  the  same  is  true  of  Wright's  hypertonic 
saline.  All  these  things,  as  is  true  of  the  treatment 
of  wounds  in  general,  come  down  to  the  basis,  more 
or  less,  of  a  personal  equation  with  the  individual 
surgeon,  and  there  has  been  a  very  extensive  con- 
troversy, particularly  in  England,  by  those  who  re- 
gard themselves  representatives  of  Lister,  versus 
those  who  are  opposed  to  the  use  of  any  antiseptics, 
and  Wright  is  their  very  capable  leader. 
Carrel,  as  you  know,  is  endeavoring  to  shorten  the 
life  of  wound-healing  by  radical  excisions  of  tissue 
after  primary  partial  sterilization  with  Dakin's 
fluid. 

"There  seems  to  me  no  'best  treatment'  for  gas 
gangrene,  for  when  gangrene  has  set  in,  it  necessarily 
means  amputation.  I  presume  that  your  question 
really  means  gas  infection,  which  is  not  such  a  dread 
condition  as  it  was  thought  to  be,  and  although  am- 
putations for  gas  infection  were  performed  during 
the  first  part  of  the  war,  they  very  soon  learned  that 
gas  infection,  short  of  gas  gangrene,  was  a  very  re- 
coverable type  of  infection. 

'Tetanus  has  absolutely  disappeared,  owing  to  the 
10 


146  TREATMENT  OF  WAR  WOUNDS 

immediate  injections  which  are  given  at  the  first-aid 
stations,  a  very  serious  blow  to  the  antivivisectionists. 

•          •          • 

"Transportation  you  will  find  a  very  serious  prob- 
lem, particularly  as  our  day  coaches — unless  holes 
can  be  cut  in  the  sides — are  absolutely  unfit  for  the 
carrying  of  wounded,  and  the  only  cars  which  have 
side  openings  are  freight  cars,  with  impossible 
springs.  .  .  . 

[As  a  commentary  upon  the  above  letters  from 
Drs.  Cabot  and  Gushing,  I  call  attention  to  the  fol- 
lowing facts  as  to  typhoid  fever: 

Mr.  Forster,  the  Financial  Secretary  for  War,  in 
a  speech  in  the  House  of  Commons  on  March  1, 
1917,*  made  this  statement:  "Nothing  was  more 
striking  than  the  triumph  of  science  over  disease, 
wholly  upsetting  the  experience  of  former  wars.  One 
of  the  most  remarkable  facts  was  the  almost  total 
disappearance  of  enteric  fever."  He  then  went  on 
to  point  out  that  in  spite  of  the  "vast  numbers  of  the 
army,  their  density  on  the  ground  and  conditions  of 
the  soil  in  France,  the  last  weekly  returns  of  the  num- 
bers of  typhoid  patients  were  as  follows:  In  France 
there  were  4  cases;  in  Salonica,  9;  Egypt,  3;  Meso- 
potamia, 8 — a  total  of  24. 

*  Brit.  Med.  Jour.,  March  10,  1917,  p.  340. 


OFFICIAL  TYPHOID  STATISTICS  147 

"The  total  number  of  cases  of  typhoid  fever  in 
British  troops  in  France  down  to  November  1,  1916, 
was  1684;  of  paratyphoid,  2534,  and  of  indefinite 
causes,  353,  making  a  total  of  4571  of  the  typhoid 
group." 

[In  our  own  Spanish- American  War  in  1898  every 
fifth  man  contracted  typhoid  fever.  If  the  same 
ratio  (1 : 5)  had  held  in  the  British  army  alone  in  the 
present  war,  there  would  have  been  about  1,000,000 
cases.  The  actual  number  has  been  less  than  one  case 
in  every  1000  men,  instead  of  one  in  every  five  men.  In 
the  German  army  also  typhoid  has  practically  disap- 
peared.] 

Mr.  Forster  called  attention  to  the  enormous  change 
since  the  Boer  War,  when,  in  their  relatively  small 
army,  there  were  60,000  cases  and  over  8000  deaths. 
He  also  made  the  following  statement:  "The  ad- 
mission ratio  of  typhoid  fever  amongst  the  troops 
in  France  who  had  not  been  protected  by  [typhoid] 
inoculation  was  fifteen  times  higher  than  among  those 
who  had  been  inoculated,  and  the  death  rate  was 
seventy  times  higher."-  — W.  W.  K.] 


148  TREATMENT  OF  WAR  WOUNDS 

LETTER  FROM  DR.  CHARLES  L.  GIBSON 

Adjunct  Professor  of  Surgery,  Cornell  University  Medical  School,  New  York 

City 

November  10,  1916. 

.  .  .  The  inclosed  is  a  dictation  I  made 
from  memory  of  the  remarks  that  I  made  at  a  recent 
meeting  of  the  Society  of  Clinical  Surgery.  .  .  . 

"Depage  showed  me  several  cases  of  gas  gangrene 
which  he  had  treated  by  injection  of  oxygen  under 
feeble  pressure  with  most  excellent  results  and  marked 
diminution  in  the  mortality.  The  area  affected  is 
penetrated  in  many  places  by  a  needle  by  which  the 
oxygen  is  introduced,  and  it  is  sought  to  have  the 
evidence  of  the  penetration  of  the  oxygen  by  its  ap- 
pearance in  the  wound.  .  .  . 

"On  arriving  at  Paris  the  first  week  in  July  I 
found  awaiting  me  a  letter  from  Carrel  saying  that 
he  had  some  interesting  things  to  show  me  in  his 
work  on  infection,  and  that  by  the  process  that  he 
was  now  using  suppuration  was  practically  elimi- 
nated. I  did  not  go  to  Compiegne  for  some  days,  and 
found  that  opinions  were  divided  in  Paris  as  to  the 
value  of  the  method.  A  small  but  enthusiastic  ma- 
jority, which  I  subsequently  joined,  were  very  much 
impressed  with  the  results  and  the  method.  This 
party  was  composed  exclusively  of  persons  who  had 


DR.  CHARLES  L.  GIBSON'S  LETTER  149 

taken  the  trouble  to  go  to  Compiegne  or  to  Depage 
at  La  Panne  and  see  for  themselves  the  method  as  it 
was  done  there  and  done  rightly.  Subsequent  ob- 
servation on  my  part  and  the  testimony  of  Carrel 
showed  that  there  were  very  few  institutions  out- 
side of  Carrel's  hospital  where  the  method  was  under- 
stood and  practised  right,  and  consequently  good  re- 
sults obtained.  Much  misconception  exists  about  the 
method,  and  I  confess  that  until  I  went  to  Compiegne 
I  had  no  conception  what  it  meant. 

"When  the  method  was  first  brought  out,  its  possi- 
bilities were  probably  exaggerated  and  some  false 
hopes  were  raised  that  by  its  use  the  tissues  could 
be  so  efficiently  sterilized  that  less  energetic  surgical 
methods  would  be  needed.  Such  an  impression  got 
abroad,  and  when  it  was  finally  seen  and  realized  that 
neither  this  method  nor  any  other  method  could  take 
the  place  of  sound  surgical  treatment, — removal  of 
infection  (foreign  bodies),  free  drainage,  surgical 
cleansing,  etc., — there  came  a  reaction  in  some 
quarters  against  the  method,  and  a  prejudice  was 
started  which  it  has  been  difficult  to  dispel  even  by 
the  proven  success  of  the  every-day  method. 

"These  wounds  [i.  e.,  those  treated  by  the  Carrel- 
Dakin  method]  heal  in  a  manner  that  is  simply  inde- 
scribable. One  has  to  see  the  behavior  of  these 


150 

sutured  wounds  oneself  to  realize  what  happens. 
They  heal  with  no  more  reaction  from  their  appear- 
ance and  manifestations  than  would  be  given  by  a 
wound  which  has  been  sutured  on  a  cadaver — total 
absence  of  reaction,  pain,  swelling,  redness,  and  even 
of  infiltration  around  the  wound-edges.  Dr.  Dehelly, 
of  Havre,  tells  me  that  he  has  closed  400  of  these 
wounds,  with  only  six  failures  to  obtain  perfect 
primary  union.  Of  these  six  mishaps,  none  were  of 
any  importance,  and  in  some  of  these  Dehelly  said 
the  fault  was  probably  due  to  his  failure  to  await 
complete  sterilization,  as  evidenced  by  the  bacterial 
count. 

"Carrel  realizes  that  the  method  requires  a  good 
deal  of  care  and  personal  attention,  and  is  seeking  to 
modify  it  by  having  an  antiseptic  which  may  be 
readily  and  continuously  diffused  all  over  the  wound 
surface.  He  would  like  to  use  it  very  much  as  one 
does  Beck's  paste,  which  permeates  every  nook  and 
cranny  of  a  given  cavity.  For  superficial  surfaces 
he  is  using  a  chloramin  ointment.  So  far  he  has  not 
been  able  to  find  a  suitable  medium  to  introduce  into 
the  deep  wounds.  He  feels  now  that  the  question  of 
sterilizing  perfectly  fresh  wounds  has  been  solved, 
and  on  my  second  visit  to  him,  nearly  two  months 
later,  I  found  he  was  just  beginning  to  try  it  out  in 


DR.  CHARLES  L.  GIBSON'S  LETTER  151 

old  infections.  He  had  just  received  a  batch  of  'neg- 
lected' cases  who  had  been  through  a  number  of 
hospitals,  and  some  had  not  had  their  dressings 
changed  in  ten  days.  Miss  R.,  a  nurse  whom  I  sent 
to  study  the  method  at  Carrel's,  is  just  back,  and  tells 
me  that  his  success  in  handling  these  old  infections 
is  apparently  going  to  be  as  great  as  in  the  fresh.  I 
talked  over  with  him  the  possibility  of  utilizing  this 
form  of  applying  an  antiseptic  to  other  forms  of  in- 
fection, and  he  believed  that  there  would  be  a  future 
for  it. 

"My  next  experience  with  the  application  of  the 
Carrel  method  was  at  the  hospital  of  Dr.  Depage,  at 
La  Panne,  Belgium.  He  has  a  wonderfully  well- 
equipped  hospital  of  800  beds,  with  everything  to 
work  with,  and,  in  fact,  six  miles  from  the  firing-line 
he  has  a  better  equipped  hospital  than  many  an  insti- 
tution in  New  York  city.  He  is  a  firm  believer  in  the 
Carrel  method,  because  he  took  the  trouble  not  only 
to  send  his  assistants  to  become  familiar  with  it,  but 
studied  it  himself  at  Compiegne.  He  has  established 
it  on  a  large  scale,  and  is  extraordinarily  satisfied 
with  its  results.  For  example,  he  made  the  statement 
that  he  had  80  compound  fractures  in  one  ward  and 
not  one  was  suppurating.  I  was  given  an  oppor- 
tunity of  seeing  the  dressings  in  this  ward,  and  in 


152  TREATMENT  OF  WAR  WOUNDS 

these  80  cases  I  can  verify  the  statement  of  Dr. 
Depage  in  that  I  did  not  see  one  single  drop  of  pus." 

LETTER  FROM  DR.  HENRY  H.  M.  LYLE 

Professor  of  Clinical  Surgery,  Columbia  University,  New  York 

January  20,  1917. 

.     .     .     At  the  front  there  are  at  least  four 
different  methods  of  treating  shell  wounds : 

"1.  The  common  or  open  treatment,  by  incision, 
drainage,  and  the  use  of  different  antiseptics,  bal- 
sams, etc.,  as  carried  out  in  civil  life. 

"2.  The  so-called  physiologic  or  hypertonic  saline 
treatment  of  wounds,  as  advocated  by  Wright. 

"3.  The  Carrel  method. 

"4.  The  treatment  of  wounds  by  the  method  of 
excision. 

"In  my  limited  experience  the  last  two  methods 
give  far  superior  results  if  carried  out  thoroughly. 
Of  the  two,  the  Carrel  method  is  the  safer  and  has 
the  wider  application.  However,  the  fourth  method, 
in  the  hands  of  experienced  and  trained  men,  gives 
the  most  brilliant  results,  and  this  often  in  places 
where  you  would  least  expect,  as,  for  example,  in 
the  joints.  The  method  calls  for  good  judgment,  the 
early  reception  of  the  patient,  and  the  retention  of 
the  patient  under  the  care  of  the  operator  for  a  long 


DR.  H.  H.  M.  LYLE'S  LETTER  153 

enough  period  to  insure  that  the  wound  is  progressing 
favorably.  If,  under  this  method,  an  infection  should 
occur,  the  Carrel  treatment  should  be  instituted  at 
once.  I  was  very  much  interested  to  note  that  this 
method  was  successfully  carried  out  by  Baron  Larrey 
in  the  Napoleonic  wars.  In  reading  his  'Memoires,' 
I  notice  he  gives  the  credit  of  originating  this  method 
to  Desault.  The  great  possibility  of  danger  in  the 
careless  application  of  this  method  has  kept  me  from 
writing  on  this  subject,  but  personally  I  feel  that  in 
properly  selected  cases,  and  carried  out  thoroughly, 
it  gives  the  best  results  of  any  of  the  methods. 

"In  all  the  above  methods,  whatever  the  after- 
treatment,  the  immediate  extraction  of  the  pro- 
jectiles, clothes,  etc.,  is  the  practice  in  the  best  front 
line  ambulances. 

"The  French  dressings  used  in  the  front  line  ambu- 
lances, and  their  method  of  applying  and  removing 
them,  are  superior  in  safety,  speed,  and  simplicity 
to  those  in  vogue  in  our  civil  hospitals." 


154  TREATMENT  OF  WAR  WOUNDS 

THE  TREATMENT  OF  GUNSHOT  WOUNDS* 
BY  SIR  BERKELEY  MOYNIHAN 

The  problem  of  the  treatment  of  gunshot  wounds 
has  been  profoundly  modified,  if,  indeed,  it  has  not 
been  radically  altered,  by  the  knowledge  gained 
during  the  present  war.  Neither  the  civil  experience 
of  the  last  forty  years,  nor  any  recent  military  ex- 
perience, had  prepared  us  for  the  kind  of  work  which, 
from  the  very  outbreak  of  the  campaign,  it  was  our 
duty,  as  surgeons,  to  perform.  The  new  and  unex- 
pected things  which  occurred  were  due  to  a  set  of 
circumstances  each  one  of  which  was  in  some  degree 
different  from  anything  we  had  observed  before. 
The  character  of  the  missiles  in  respect  to  the  mode 
of  flight  and  velocity  was  not  that  with  which  former 
wars  had  made  us  familiar.  The  damage  inflicted 
upon  the  tissues  was  far  greater  than,  and  different 
in  quality  from,  that  commonly  seen  in  South  Africa; 
the  organisms  carried  into  the  wound  from  the  sur- 
face of  the  body,  from  the  earth  around,  or  by  frag- 
ments of  clothing,  judged  by  their  clinical  results, 
transcend  in  virulence  or  in  fecundity  anything  known 
by  the  present  generation  of  surgeons;  and,  finally, 

*  Brit.  Med.  Jour.,  March  4,  1916,  p.  333.  (Resume  by  Dr. 
Keen.) 


DR.  FRED.  T.  MURPHY'S  LETTER  155 

the  soldier,  in  the  earlier  months  of  the  war  at  least, 
had  undergone  so  serious  and  prolonged  a  strain, 
before  being  wounded,  that  he  often  fell  an  easy  vic- 
tim to  a  bacterial  onslaught  of  great  ferocity.  .  .  . 
Lister  clearly  distinguished  the  difference  between 
the  prophylactic  and  the  therapeutic  value  of  anti- 
septics; he  emphasized  the  great  importance  of  the 
former,  and  pointed  out  the  inadequacy  of  the  latter. 
The  work  of  surgeons,  since  Lister  taught,  has  de- 
pended for  its  almost  incredible  success  upon  the 
prevention  of  infection  in  wounds  deliberately  in- 
flicted— not  upon  the  control  of  an  infection  already 
established. 

LETTER  FROM  DR.  FRED.  T.  MURPHY 

Professor  of  Surgery,  Washington  University  Medical  School,  St.  Louis,  Mo. 

December  29,  1916. 
Conditions  vary  so  on  the  Continent, 
as  well  as  the  character  of  the  material,  that  any  ex- 
pression of  opinion  as  to  treatment  must  be  recog- 
nized as  only  a  personal  opinion.  I  was  very  much 
impressed  by— 

"1.  The  use  of  antitetanic  serum. 

"2.  The  great  importance  of  the  period  of  time 
elapsing  between  the  receipt  of  the  wound  and  the 
establishment  of  final  surgical  treatment. 


156  TREATMENT  OF  WAR  WOUNDS 

"3.  The  application  of  the  various  types  of  fixa- 
tion apparatus. 

"4.  The  use  of  special  solutions  for  irrigation. 

"5.  The  cooperation  between  the  dentist  and  sur- 
geon. 

"6.  The  necessity  of  the  preservation  of  all  loose 
spicules  of  bone  in  compound  fractures. 

"To  comment  very  briefly  upon  these  impressions: 
The  system  of  giving  antitetanic  serum  has  been  so 
perfected  that  practically  every  wounded  man  re- 
ceives his  injection  within  the  first  few  hours  after 
the  injury.  Cases  of  tetanus  were  practically  never 
seen  in  Paris.  Now  and  again  an  atypical  late  case 
has  been  observed. 

"In  comparing  the  wards  at  Compiegne  and  La 
Panne,  where  the  wounded  were  received  within  the 
first  two  to  six  hours  after  injury,  with  those  at  Paris, 
where  they  were  received  days  and  weeks  after  they 
had  been  wounded,  it  was  difficult  to  believe  that  the 
wounds  in  both  places  had  been  originally  of  the  same 
character. 

"In  the  use  of  plaster  with  the  supporting  metal 
strips  for  fixation  of  the  extremities  in  transit  it 
seems  to  me  that  a  distinct  contribution  has  been 
made  to  surgical  equipment.  This  plaster  was  ap- 
plied next  to  the  skin,  and  the  fixation  was  such  that 


DR.  FRED.  T.  MURPHY'S  LETTER  157 

the  tissues  were  not  further  lacerated,  the  patient 
was  made  comfortable,  and  there  was  ample  oppor- 
tunity for  any  dressings  that  might  be  needed.  The 
balanced  splints  swinging  from  an  overhead  support 
which  have  come  into  such  general  use  in  the  hos- 
pitals seem  to  me  also  to  be  a  very  valuable  addition 
to  our  surgical  apparatus.  By  these  splints  the  pa- 
tients were  made  very  comfortable;  they  were  al- 
lowed a  freedom  of  motion  that  would  have  been 
impossible  with  any  other  type  of  apparatus;  and 
yet  extension  and  fixation  could  be  maintained  per- 
fectly satisfactorily.  Also  it  was  possible  to  carry 
out  irrigation  and  to  do  dressings  in  a  way  which 
would  have  been  impossible  with  the  older  type  of 
support. 

"  One  saw  many  solutions  used  for  irrigation.  That 
of  Carrel,  the  so-called  Dakin's,  seemed  to  me  to  be 
the  only  one  which  had  given  such  results  as  to  war- 
rant any  very  special  consideration.  I  could  not  see 
that  solutions  of  quinin  or  dilute  alcohol  or  iodin 
were  to  be  preferred  to  salt  solution.  Such  conserva- 
tive observers  as  Tuffier  and  Depage  thought  very 
highly  of  the  Dakin  solution  for  irrigation.  Cer- 
tainly at  Compiegne  and  La  Panne  the  wounds  were 
in  very  good  condition.  I,  personally,  feel  that  the 
detail  with  which  the  treatment  was  carried  out  by 


158  TREATMENT  OF  WAR  WOUNDS 

Carrel  and  the  type  of  the  cases  under  treatment  had 
very  possibly  a  very  material  effect  on  these  results. 

"By  the  cooperation  between  the  dentists  and  sur- 
geons results  were  and  are  being  obtained  which  are 
nothing  shprt  of  miraculous.  To  turn  these  extensive 
jaw  injuries  over  to  the  dentist  without  surgical 
supervision  would,  I  am  sure,  be  a  mistake,  but  by 
the  application  of  proper  prosthetic  appliances, bone 
fragments  are  preserved  and  contractures  are  pre- 
vented, so  that  the  surgeon  has  a  bony  framework 
over  which  to  apply  the  plastic  which  would  be  to  a 
large  extent  lacking  without  this  preliminary  treat- 
ment. 

"At  the  ambulance  we  had  the  opportunity  to 
compare  cases  from  two  hospitals  near  the  line  at 
which  entirely  different  ideas  were  carried  out  in 
treating  the  compound  fractures.  In  the  one,  all 
loose  fragments  were  removed  and  the  ends  smoothed 
off.  In  the  other,  practically  nothing  was  done  but 
to  insert  drainage-tubes  into  the  lacerated  mass. 
The  difference  seen  between  the  results  of  treatment 
was  most  startling.  After  removal  of  the  loose  frag- 
ments of  bone,  union  was  delayed  and  prevented  in 
many  cases,  and  by  the  resection  of  the  ends  of  the 
shattered  bones  flail  extremities  were  left  which  were 
practically  useless.  On  the  other  hand,  in  the  cases 


DR.  FRED.  T.  MURPHY'S  LETTER  159 

based  on  ultra-conservative  treatment  the  results 
were  practically  uniformly  satisfactory.  Provided 
the  spicules  were  not  removed,  there  seemed  to  be 
almost  no  limit  to  the  amount  of  shattering  which 
might  be  followed  by  a  complete  reestablishment  of 
the  shaft. 

"From  the  work  of  Taylor,  and  from  the  large 
clinical  experience  of  the  men  with  gas  gangrene, 
it  seemed  to  me  that  the  treatment  had  been  reduced 
to  very  simple  essentials;  that  is,  the  removal  of 
non-viable  muscle  and  sufficiently  free  incisions  so 
that  muscle  could  not  be  further  strangulated  under 
the  fascial  planes  from  the  tension  following  the  gas 
production.  As  soon  as  dead  muscle  is  removed  as  a 
culture-medium,  the  activity  of  the  Bacillus  aerogenes 
is  very  sharply  limited.  Personally,  I  was  not  favor- 
ably impressed  by  the  use  of  oxygen  injected  into 
the  tissues.  It  seemed  to  me  that  the  trauma  of  this 
injection  did  more  harm  than  good. 

"We  had  no  opportunity  at  Paris  to  see  the  num- 
ber of  cases  treated  by  Sir  Almroth  Wright's  method. 
I  should  judge,  from  the  personal  reports  which  I 
heard  from  men  who  had  seen  the  method  used  at  the 
English  bases,  that  the  results  had  not  been  very 
satisfactory." 


APPENDIX 

ADHESIVE  PLASTER  FOR  EXTENSION  IN  FRACTURES 
From  the  British  Medical  Journal  of  July  14,  1917, 
p.  60, 1  append  what  is  apparently  a  useful  means 
for  applying  extension  in  fractures,  especially  of  the 
lower  extremity: 

"Last  August  we  published  a  note  on  a  method  of 
fixing  extension  to  fractured  limbs  by  the  use  of 
a  glue  adhesive,  introduced  by  Major  M.  Sinclair, 
R.A.M.C.,  for  use  especially  in  the  application  of 
the  extension  to  compound  fractures  of  the  lower 
limb.  As  we  have  received  inquiries  with  regard  to 
this,  we  have  obtained  information  as  to  the  formula 
at  present  used  and  the  method  of  application.  The 
formula  in  general  use  is  as  follows : 

Ordinary  glue 50  parts 

Water 50     " 

Glycerin 2 

Calcium  chlorid 2     " 

Thymol 1  part 

"The  glycerin  and  calcium  chlorid  are  both  deli- 
quescent and  take  up  the  perspiration,  which  keeps 
the  glue  from  getting  brittle,  and,  more  important 
still,  allows  perspiration  to  take  place.  This  pre- 
vents the  skin  from  getting  sodden,  in  which  condi- 

160 


APPENDIX  161 

tion  bacteria  may  flourish  and  give  rise  to  skin 
troubles.  The  thymol  is  added  to  prevent  putre- 
faction and  diminish  smell.  Every  time  the  ad- 
hesive is  heated  the  odour  gets  less  and  less.  Ex- 
periments have  proved  that  bacteria  do  not  grow  on 
this  preparation.  Air-tight  tins  which  hold  about  a 
pound  are  filled  and  sterilized  at  100°  and  placed  in 
store.  When  required,  the  contents  are  melted  in  a 
water-bath,  and  set  aside  a  few  minutes  to  cool. 

"The  adhesive  is  applied  with  the  palm  of  the  hand 
or  a  brush.  The  skin  is  washed  with  soap  and 
sodium  carbonate  solution  (four  drachms  to  the  pint) 
in  order  to  remove  fat,  and  when  dry  the  adhesive  is 
applied  without  shaving  the  part.  The  area  is  cov- 
ered evenly,  and  the  ordinary  four-ply  gauze  as  it 
comes  out  of  the  packet  applied,  having  roughly 
measured  the  requirements  and  gathered  it  in  at  the 
level  of  the  wrist  or  ankle.  An  alternative  method  is 
to  put  on  a  length  of  'Elastic  cotton  net  bandage' 
(S.  Maw)  from  knee  to  ankle,  to  glue  it  on  the  out- 
side,  and  then  to  apply  the  gauze  as  above  and  ban- 
dage carefully  with  a  thin  bandage. 

"The  gauze,  being  spread  out  fan-shaped,  adapts 
itself  to  the  conformity  of  the  limb,  and  is  kept  in 
apposition  with  the  skin  by  a  loose  woven  bandage. 
The  extension  can  be  made  almost  immediately. 

"The  above  method  of  extension  is  a  very  great 
saving  of  time,  and,  when  compared  with  the  cost  of 
good  strapping,  is  as  sixpence  to  three  shillings  a 

limb.     The  following  slight  modification  in  the  for- 
11 


162  APPENDIX 

mula  gives  an  excellent  adhesive  which  is  a  little 

more  elastic: 

Isinglass 50  parts 

Glue 50     " 

Water 50     " 

Calcium  chlorid 2     " 

Tannic  acid 12 

Thymol 1  part 

Glycerin 2  parts 

ACRIFLAVINE,  PROFLAVINE,  AND   BRILLIANT   GREEN 

At  the  last  moment  I  found  the  most  important 
paper  yet  published  on  these  new  antiseptics  by 
Browning,  Gulbransen,  and  Thornton,  in  the  British 
Medical  Journal,  July  21,  1917,  page  70. 

Acriflavine  and  Proflavine. — The  principal  points 
brought  out  by  their  experiments  are: 

First. — That  the  bactericidal  power  of  acriflavine 
and  proflavine,  instead  of  being  diminished  and 
eventually  destroyed  by  the  addition  of  blood  serum, 
as  is  the  case  with  hypochlorites,  mercuric  chlorid, 
etc.,  is  actually  increased  from  ten  to  forty  fold. 

Second. — As  a  result,  these  two  antiseptics,  while 
they  act  at  first  merely  by  inhibiting  bacterial 
growth,  later  become  increasingly  powerful,  actively 
destroying  the  bacteria.  "After  two  hours'  contact 
in  the  presence  of  serum,  mercuric  chlorid  is  prac- 
tically equal  to  acriflavine  in  its  lethal  effect  on 
staphylococcus  and  B.  coli.  But  by  this  time  the 
effective  action  of  the  mercury  salt  on  the  bacteria 
has  come  to  an  end,  and  a  concentration  which  has 


APPENDIX  163 

then  failed  to  kill  the  organisms  exerts  subsequently 
little  or  no  inhibitory  effect  on  the  proliferation  of  the 
survivors.  On  the  other  hand,  concentrations  of  the 
flavines,  which  at  this  period  have  merely  inhibited 
multiplication,  later  on  prove  bactericidal,  so  that 
finally  the  flavine  compound  is  ten  to  twenty  times 
more  lethal  than  corrosive  sublimate." 

Hence,  instead  of  renewing  the  solutions  every 
two  hours,  only  one  or  two  daily  dressings  are  re- 
quired. 

Third. — They  are  apparently  harmless  to  the 
tissues.  "Experiments  show  that  such  concentra- 
tions of  flavine,  while  effectively  controlling  the  bac- 
teria, do  not  interfere  with  phagocytosis." 

Brilliant  Green. — Brilliant  green,  like  the  hypo- 
chlorites,  in  the  presence  of  serum  soon  loses  its 
value  as  a  bactericide;  hence  if  used,  it  must  be  re- 
newed at  frequent  intervals.  But,  on  the  other 
hand,  "it  possesses  the  advantage  of  being  an  ex- 
tremely potent  bactericide, — far  exceeding  the  fla- 
vines in  watery  solution, — while  at  the  same  time  it  is 
comparatively  harmless  to  phagocytosis,  as  well  as 
to  the  tissues  locally,  and  when  applied  to  a  wound, 
it  is  devoid  of  general  toxic  action  on  the  body." 
Its  use  by  Lt.-Col.  Hull,  of  the  British  Army,  by  two- 
hourly  flushings  after  Carrel's  method,  has  proved 
most  encouraging. 

In  burns  also  irrigation  of  brilliant  green,  followed 
by  paraffin  treatment,  Col.  Hull  has  found  superior 
to  any  other  treatment. 


INDEX 


ABDOMEN,  wounds  of,  115 
Bowlby's  letter,  132 
Cabot's  letter,  135 
mortality  from,  120 

Abdominal  cases,  Bowlby  on,  20 

Acriflavine,  34,  162 

Adhesive,  use  of,  in  extension  for  frac- 
tures, 161 

Ambrine,  122 

Bowlby's  letter,  131 

Ambulance,  Cabot's  letter,  137 
motor,  importance  of,  20 
railway,  24 

American  Field  Ambulance,  21 
hospitals,  location  of,  17 

Antisepsis,  33 

Antiseptics,  new,  34 

Antitetanic  serum,  77 
curative  dosage,  83 
prophylactic  dosage,  78 

Antitoxin  to  prevent  gas  gangrene,  95 

Archibald   and   Maclean  on  need  of 
warmth,  15 

Armor,  use  of,  12 

Asepsis,  33 

Automobile  ambulance,  21 

Automobiles,  importance  of ,^20,  21 


Bacillus  perfringens,  89 

Welchii,  89 

Bacteria  of  wound  infection,  31 
Balkan  splint,  27 
Barges,  hospital,  26 

12  165 


Barling  on  joint  wounds,  114 
Base  hospital,  18 
Beiter  on  treatment  of  burns,  124 
Blake,  Joseph  A.,  letter  from,  126 
Blake's  splint,  26 
Blood-pressure,  taking  of,  14 
Bowel,  wounds  of,  117 
Bowlby,  Sir  Anthony  A.,  letter  from, 
128 

on  British  surgery  at  the  front,  20 

on  burns,  125 

on  gas  gangrene,  91 

on  head  wounds,  105 

on  joint  wounds,  112 

on  restoratives  for  wounded,  15 
Bowling  on  tetanus,  75 
Brain,  foreign  bodies  in,  104 

removal  of  bullets  from,  108 

wounds  of,  101 
Brilliant  green,  162 
Browning's  acriflavine,  34 
Bull  and  Pritchett,  antitoxin  for  gas 

gangrene,  95 
Bullets,  character  of  wounds,  29 

removal  of,  from  brain,  108 
Burns,  122 


CABOT,  Hugh,  letter  from,  133 
on  standardized  stretchers,  21 

Caldwell,  E.  W.,  on  stereo-fluoroscopy, 
68 

Carbolic  acid  in  treatment  of  tetanus, 
84 


166 


INDEX 


Carrel  on  wound  infection,  31 
Carrel-Dakin  method,  40.    See  Dakin- 

Carrel  method 

Casualty  clearing  station,  19,  20 
Chase  on  plaster  casts,  26 

on  war  wounds,  30 
Chattaway's    method    for    preparing 

dichloramin-T,  63 
Chest,  foreign  body  in,  111 

wounds  of,  110 

Bowlby's  letter,  132 
Chlorinated  eucalyptol,  65 

paraffin  oil,  65 

Compound  fractures  and  no  pus,  37 
Corselets,  steel,  12 
Cranial  wounds,  100 
Crile,  George  W.,  letter  from,  143 

on  exhaustion  of  soldiers,  33 

on  use  of  morphin,  27 
Curve    of    healing    in    Dakin-Carrel 

method,  57 
Gushing,  Harvey,  letter  from,  144 

on  cranial  wounds,  100 


DAKIN-CARREL  method,  40 
after-care  of  wounds,  53 
bacteriologic       examination 

wound,  54 
Bowlby's  letter,  129 
Cabot's  letter,  140 
Crile's  letter,  143 
Cushing's  letter,  145 
introduction  of  tubes,  50 
Lyle's  letter,  152 
Murphy's  letter,  157 
necessary  materials,  46 
objections  to,  60 
preparation  of  the  wound,  48 
reunion  of  wound,  55 
the  solution.  4 1 
Gibson's  letter,  148 


of 


Dakin's  fluid,  40 
Blake  on,  127 

Daufresne's  technic  for  Dakin's  so- 
lution, 41 

Decompression  operations,  104 

Delayed  tetanus,  75 

Depage  on  the  Carrel-Dakin  method, 
37 

Diastolic     pressure,     importance     of 
taking,  14 

Dichloramin-T,  61 
preparation  of,  62 

Dressing  stations,  18,  19 

Dysentery,  Cabot's  letter,  137 

EUPAD,  39 

Eusol,  39 

Evacuation  hospital,  18 

of  wounded,  16-19 
Excision    of    tissues    surrounding    a 

wound,  29-32 
Exhaustion  of  soldiers,  33 
Extension  in  fractures,  160 

FIELD  ambulance,  operations  at,  135 

hospital,  18,  19 
First-aid  station,  18 
Flavine,  34 

Foreign  bodies  in  brain,  104 
in  the  chest,  111 
removal  of,  68 
Fowler  position,  120 
Fractures,  extension  in,  160 

Murphy's  letter,  158 

splints  for,  26 
Fraser  &  Drummond  oh  abdominal 

wounds,  117 

GANGRENE,  gas,  89 

antitoxin  to  prevent,  95 


INDEX 


167 


Gangrene,  hospital,  98 

Gans's  attachment  for  motor  car,  21 

Gas  gangrene,  89 

antitoxin  for,  95 

Blake's  letter,  127 

Bowlby's  letter,  130 

Crile's  letter,  143 

Cushing's  letter,  145 

Gibson's  letter,  148 

Murphy's  letter,  159 

treatment  of,  93 
infection,  89 

Blake  on,  127 

Cabot's  letter,  139 

treatment  of,  93 
Germicides,  34 
Gibson,  Charles  L.,  letter  from,  148 

on  tetanus,  74 

Glue  adhesive,  use  in  fracture  exten- 
sion, 160 
Goodwin,  Col.,  on  transportation  of 

wounded,  17,  19 
Gunshot  wounds,  28 

of  head,  100 

treatment  of,  Sir  Berkeley  Moyni- 
han  on,  154 

HEAD,  wounds  of,  100 
Bowlby's  letter,  132 
Cushing's  letter,  144 
Healing,  curve  of,  57 
Helmets,  use  of,  12 
Herringham  on  wounds  of  the  chest, 

110 
Holmes,     G.,     on     temperatures     in 

wounded,  16 
Holmes  and  Sargent  on  head  wounds, 

108 
Hospital  barges,  26 

gangrene,  98 

trains,  25 


Hospitals,  American,  location  of,  17 
British,  location  of,  17 
relation  of,  to  army  in  field,  16-20 
sudden  flooding  with  patients,  13 

Huge  numbers  in  contending  armies,  13 

Hull  on  paraffin  dressings  for  burns, 
122 

Hydrogen  peroxid  irrigations  in  tet- 
anus, 85 

Hypochlorous  solution,  39 

INFECTION,  new  methods  of  treating, 

36 

of  wounds,  30 
tetanus,  74 

treatment  of,  Cabot's  letter,  139 
Intestine,  resection  of,  118 

wounds  of,  1 17 

Intrathecal  injection  of  tetanus  anti- 
toxin, 83,  87 

JOINTS,  wounds  of,  112 

KIDNEYS,  wounds  of,  119 
Knee-joint,  wounds  of,  112 

LETTER  from  Charles  L.  Gibson,  148 
from  Fred.  T.  Murphy,  155 
from  George  W.  Crile,  143 
from  Harvey  Gushing,  144 
from  Henry  H.  M.  Lyle,  152 
from  Hugh  Cabot,  133 
from  Joseph  A.  Blake,  126 
from  Sir  Anthony  A.  Bowlby,  128 
from  Sir  Berkeley  Moynihan,  154 
Line  of  communication,  18 
Lockwood  on  abdominal  wounds,  1 17 
Longitudinal  sinus  syndrome,  108 
Lyle,  Henry  H.  M.,  letter  from,  152 
on  Dakin's  fluid,  43 


168 


INDEX 


MAGNESIUM  sulphate  in  treatment  of 

tetanus,  84 
Makins  on  head  wounds,  106 

on  hospital  gangrene,  98 
Mercurophen,  35 

Morphin,  value  of,  in  wounded,  27 
Motor    ambulance,    importance    of, 

20 

Moynihan,  Sir  Berkeley,  letter  from, 
154 

on  tetanus,  75 
Multiple  wounds,  30 
Murphy,  Fred.  T.,  letter  from,  155 

NAVY,  wounds  in,  32 
Nephrectomy,  120 

OXYGEN  injections   in  gas   infection, 
93 


PAGE,  Col.  Henry,  on  transportation 

of  wounded,  16,  18 
Paraffin  dressing  for  burns,  122 
Planimeter,  57 
Plaster,  Chase's  hint,  26 

use  of,  Murphy's  letter,  156 
Porter  on  shock,  14 
Position  of  wounded,  14 
Proflavine,  35,  162 

RADIOSCOPY  of  foreign  bodies,  68 
Railway  ambulance  trolley,  24,  25 
Removal  of  foreign  bodies,  68 
Resection  of  intestine,  118 


SARGENT  on  head  wounds,  106 
Sargent  and  Holmes  on  contralateral 
decompression,  104 


Shell  wounds,  character  of,  28 
Shock  at  the  front,  14 

treatment  of,  15 
Shrapnel  wounds,  28 
Sinclair's    method   of    extension   for 

fractures,  160 
Skull,  wounds  of,  100 
Sodium     hypochlorite     solution,    40. 

See  Dakin's  fluid 
Soil,  factor  in  wound  infection,  30 
Splints,  26 

Balkan,  27 

Blake's,  26 

Cabot's  letter,  138 
Stereo-fluoroscopy   in  localizing  and 

extracting  foreign  bodies,  68 
Stereoscopic  x-ray,  68 
Streptococcus  infection,  98 
Stretchers,  standardized,  21 

TAYLOR  (Kenneth)  method  of  ob- 
taining pure  culture  of  Bacillus 
Welchii,  90 

Temperature  of  wounded,  15,  16 

Tetanus,  74 

antitetanic  serum  in,  77 

Cabot's  letter,  135 

care  of  cases,  85 

delayed,  75 

diagnosis,  79 

intrathecal    injection,    method    of 

performing,  87 
injection  of  antitoxin,  83 
memorandum  on,  by  British  War 

Office  Committee,  77 
Murphy's  letter,  156 
preventive  treatment  of,  77 
prophylaxis  in,  77 
surgical  treatment  of  the  wound,  84 
therapeutic  treatment,  81 
treatment  of,  carbolic  acid,  84 


INDEX 


169 


Tetanus,   treatment    of,    magnesium 

sulphate,  84 
specific,  82 
Thomas  splint,  27 
Time,    importance    of,    in    treating 

wounded,  13 

Tissier  on  gas  gangrene,  90 
Tissue,  removal  of,  in  gas  infection,  93 
Trains,  hospital,  25 
Transportation,  Cabot's  letter,  137 

Cushing's  letter,  146 

of  wounded,  16 

treatment  during,  27 
Trench  feet,  paraffin  dressing  in,  124 
Trolley,  ambulance,  25 

transportation  by,  25 
Typhoid  fever,  146 
Cabot's  letter,  136 


WALLACE,  Hughes  and  Rees  on  ab- 
dominal wounds,  115 

War,   present,   contrasted   with   pre- 
ceding wars,  12 

Warmth,  need  of,  for  wounded,  15 

Weapons,  new,  28 

Welch's  bacillus,  89 

Wounded,  collection,  evacuation  and 

distribution  of,  16-20 
huge  numbers  of,  13 
position  of,  14 
removal  of,  16 


Wounded,  transportation  of,  16 
Wounds  by  bullets,  29 
by  shells,  28 
by  shrapnel,  28,  29 
character  of,  in  present  war,  Cab 

letter,  134 

complications  of,  29,  30 
excision  of  tissues  around,  29 
infection  of,  30 

tetanus,  74 
multiple,  30 
of  abdomen,  115 

Bowlby's  letter,  132 

Cabot's  letter,  135 
of  chest,  110 

Bowlby's  letter,  132 
of  head,  100 

Bowlby's  letter,  132 

Cushing's  letter,  144 
of  intestine,  1 17 
of  joints,  112 
of  kidney,  119 

Wright  on  wound  infection,  31 
Wright's  (Sir  Almroth)  method,  126 
Bowlby's  letter,  129 

X-RAY  in  chest  wounds,  111 

localization  of  foreign  bodies,  68 
stereoscopic,  68 

ZONE  of  activity,  18 


M 

Mi 

Mot 

20 

Mov 


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F.  SCHAMBERG,  M.  D. ,  Professor  of  Dermatology  and  the  In- 
fectious Eruptive  Diseases,  Philadelphia  Polyclinic.  Octavo  of 
585  pages,  illustrated.  Cloth,  $3.25  net. 

THIRD  EDITION— published  September,  1915 

Dr.  Schamberg  takes  up  all  diseases  of  the  skin,  giving  special 
emphasis  to  those  diseases  met  most  frequently  in  general  practice. 
The  work  is  particularly  full  on  actinotherapy,  rontgenotherapy,  and 
radium,  these  modern  measures  being  discussed  in  a  separate  chap- 
ter as  well  as  under  the  various  diseases.  The  exanthemata  are 
considered  in  a  special  chapter,  diagnosis  and  treatment  being  given 
unusual  space.  In  addition,  there  are  described  the  usual  and  the 
accidental  eruptions  occurring  in  such  diseases  as  typhoid,  epidemic 
cerebrospinal  meningitis,  influenza,  malaria,  tonsillitis,  etc.  This 
is  an  important  feature.  All  the  new  vaccines  and  serums  are  con- 
sidered— their  use  both  in  diagnosis  and  treatment.  The  many 
comparative  tables  of  symptoms  and  the  wealth  of  reliable  pre- 
scriptions make  "  Schamberg  "  a  most  practical  work  for  the  gen- 
eral practitioner  as  well  as  for  the  specialist. 

Johns  Hopkins  Hospital  Bulletin 

"The  descriptions  of  the  eruptions  are  so  clear  and  concise  that  the  appearance  of  a 
disease  can  readily  be  imagined.  The  arrangement  of  diagnosis  of  many  of  the  diseases  is 
excellent,  the  points  considered  being  placed  opposite  one  another  in  parallel  rows." 

Asher's  Chemistry  &  Toxicology  for  Nurses 

CHEMISTRY  AND  TOXICOLOGY  FOR  NURSES.  By  PHILIP  ASHER, 
PH.  G.,  M.  D.,  Dean  and  Professor  of  Chemistry,  New  Orleans  Col- 
lege of  Pharmacy.  I2mo  of  190  pages.  Cloth,  $1.25  net 

Dr.  Asher's  one  aim  in  writing  this  book  was  to  emphasize  throughout  the  applica- 
tion of  chemical  and  toxicologic  knowledge  in  the  practice  of  nursing.  This  he  has 
succeeded  in  doing.  The  nurse,  both  in  training-school  and  in  graduate  practice, 
will  find  it  extremely  helpful  because  the  subject  is  made  so  clear.  October,  1914 


GENITO-  URINAR  Y  DISEASES. 


Morris'  Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  CHARLES  C.  NORRIS,  M.  D., 
Instructor  in  Gynecology,  University  of  Pennsylvania.  With  an 
Introduction  by  JOHN  G.  CLARK,  M.  D.,  Professor  of  Gynecology, 
University  of  Pennsylvania.  Large  octavo  of  520  pages,  illus- 
trated. Cloth,  $6.50  net ;  Half  Morocco,  58.00  net. 

A  CLASSIC 

Dr.  Norris  here  presents  a  work  that  is  destined  to  take  high  place  among 
publications  on  this  subject  He  has  done  his  work  thoroughly.  He  has 
searched  the  important  literature  very  carefully,  over  2300  references  being 
utilized.  This,  coupled  with  Dr.  Norris'  long  experience,  gives  his  work  the 
stamp  of  authority.  The  chapter  on  serum  and  vaccine  therapy  and  organo- 
therapy is  particularly  valuable  because  it  expresses  the  newest  advances, 
Every  phase  of  the  subject  is  considered :  History,  bacteriology,  pathology 
sociology,  prophylaxis,  treatment  (operative  and  medicinal },  gonorrhea  during 
pregnancy,  parturition  and  the  puerpe rium,  diffuse  gonorrheal  peritonitis,  and 
all  other  phases.  Further,  Dr.  Norris  considers  the  rare  varieties  of  gonorrhea 
occurring  in  men,  women,  and  children.  Published  May,  1913 


Coolidge  on  Nose  and  Throat 

Manual  of  Diseases  of  the  Nose  and  Throat.  By  ALGERNON 
COOLIDGE,  M.  D.,  Professor  of  Laryngology,  Harvard  Medical 
School.  Octavo  of  360  pages,  illustrated.  Cloth,  $1.50  net. 

READY  REFERENCE 

This  new  book  furnishes  the  student  and  practitioner  a  guide  and  ready 
reference  to  the  important  details  of  examination,  diagnosis,  and  treatment. 
Established  facts  are  emphasized  and  unproved  statements  avoided.  Anat- 
omy and  physiology  of  the  different  regions  are  reviewed. 

Published  September,  1915 


SAUNDERS'  BOOKS  ON 


Bra&sch's  Pyelog'raphy 

Pyelography  (Pyelo-Ureterography).  By  WILLIAM  F. 
BRAASCH,  M.  D.,  Mayo  Clinic,  Rochester,  Minn.  Octavo  of 
323  pages,  with  296  pyelograms.  Cloth,  $5.00  net. 

296  PYELOGRAMS 

This  new  work  is  the  first  comprehensive  collection  of  pyelograms  ever 
issued  in  book  form.  The  300  pyelograms  included  were  selected  from 
several  thousand  made  at  the  Mayo  Clinic  during  the  past  five  years.  You  get 
the  outlines  of  normal  pelves,  those  of  pathologic  conditions,  and  those  of  con- 
genitally  abnormal  pelves.  In  addition  to  the  pyelograms,  you  get  a  des- 
criptive text,  intrepreting  the  outlines,  pointing  out  their  great  value  in  diagnosis. 
You  get  the  history  of  pyelography  and  the  exact  technic — selection  of 
medium  to  be  injected,  preparation  of  solution,  method  of  injection,  sources 
of  error,  etc.  The  work  is  a  most  complete  one,  beautifully  gotten  up,  and 
contains  much  matter  of  great  diagnostic  value.  Published  March,  1915 


Ogden  on  the  Urine  Third  Edition 

CLINICAL  EXAMINATION  OF  URINE  AND  URINARY  DIAG- 
NOSIS. A  Clinical  Guide  for  the  Use  of  Practitioners  and 
Students  of  Medicine  and  Surgery.  By  J.  BERGEN  OGDEN, 
M.  D.,  Medical  Chemist  to  the  Metropolitan  Life  In- 
surance Company,  New  York.  Octavo,  418  pages,  54  text- 
illustrations,  and  a  number  of  colored  plates.  Cloth,  $3.00 

net.  Published  October,  1909 

"We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own 
experience,  so  clearly  stated,  renders  the  volume  a  useful  one  both  for  study 
and  reference." — The  Lancet,  London. 

Vecki's  Sexual  Impotence  rath  Edition 

SEXUAL  IMPOTENCE.  By  VICTOR  G.  VECKI,  M.  D. 
izmo  volume  of  400  pages.  Cloth,  $2.25  net. 

"A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The 
treatment  of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating 
and  judicious." — Johns  Hopkins  Hospital  Bulletin.  Published  December,  1915 


DISEASES   OF  THE  EYE. 


DeSchweinitzV 
Diseases  of  the  Eye 

The  New  (8th)  Edition 

Diseases  of  the  Eye:  A  HANDBOOK  OF  OPHTHALMIC 
PRACTICE.  By  G.  E.  DESCHWEINITZ,  M.  D.,  Professor  of 
Ophthalmology  in  the  University  of  Pennsylvania,  Philadelphia, 
etc.  Handsome  octavo  of  754  pages,  386  text-illustrations, 
and  7  chromo-lithographic  plates.  Cloth,  $6.00  net ;  Half 

MorOCCO,    $7.50   net.  Published  June,  1916 

WITH   386  TEXT-ILLUSTRATIONS  AND  7  COLORED  PLATES 

Dr.  deSchweinitz's  book  has  long  been  recognized  as  a  standard  authority 
upon  eye  diseases,  the  reputation  of  its  author  for  accuracy  of  statement 
placing  it  far  in  the  front  of  works  on  this  subject.  For  this  edition  Dr. 
deSchweinitz  has  subjected  his  book  to  a  most  thorough  revision.  Many 
new  subjects  have  been  added,  a  number  in  the  former  edition  have  been 
rewritten,  and  throughout  the  book  reference  has  been  made  to  vaccine  and 
serum  therapy,  to  the  relation  of  tuberculosis  to  ocular  disease,  and  to  the 
value  of  tuberculin  as  a  diagnostic  and  therapeutic  agent. 

The  text  is  fully  illustrated  with  black  and  white  cuts  and  colored  plates, 
and  i.i  every  way  the  book  maintains  its  reputation  as  an  authority. 

Johns  Hopkins  Hospital  Bulletin 

"  No  single  chapter  can  be  selected  as  the  best.  They  are  all  the  product  of  a  finished 
authorship  and  the  work  of  an  exceptional  ophthalmologist.  The  work  is  certainly  one  of 
the  best  on  ophthalmology  extant,  and  probably  the  best  by  an  American  author." 

deSchweinitz    and    Holloway    on    Pulsating 
Exophthalrnos  Published  August,  iocs 

PULSATING  EXOPHTHALMOS.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  GEORGE  E.  DESCHWEINITZ,  M.  D.,  and  THOMAS 
B.  HOLLOWAY,  M.  D.  Octavo  of  125  pages.  Cloth,  $2.00  net. 

"  The  book  deals  very  thoroughly  with  the  whole  subject,  and  in  it  the  most  com 
plete  account  of  the  disease  will  be  found." — British  Medical  Journal. 

Jackson's  Essentials  of  Eye      Fourth  Revised  Edition 

ESSENTIALS  OF  REFRACTION  AND  OF  DISEASES  OF  THE  EYE.  By 
EDWARD  JACKSON,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of  the 
Eye,  Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illustra- 
tions. Cloth,  $1.25  net.  In  Sounders'  Question-Corn pend  Series. 

"The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation  are 
made  clear  and  easy." — Johns  Hopkins  Hospital  Bulletin.  Published  April,  l^Oo 


SAUNDERS'    BOOKS   ON 


GET  ^m    ^im-m  .s-v  ^*       ^%  *-k   «-«  I  HIE*         W  t*W 

THE  BEST  /VtnCriCan  STANDARD 

Illustrated  Dictionary 

The  New  (8th)  Edition 

The  American  Illustrated  Medical  Dictionary.     A  new 

and  complete  dictionary  of  the  terms  used  in  Medicine,  Surgery, 
Dentistry,  Pharmacy,  Chemistry.  Veterinary  Science,  Nursing, 
and  all  kindred  branches;  with  over  100  new  and  elaborate 
tables  and  many  handsome  illustrations.  By  W.  A.  NEWMAN 
BORLAND.  M.  D.  Large  octavo  of  1137  pages.  Flexible  leather, 
$4.50  net ;  with  thumb  index,  §5.00  net.  Published  August,  i9is 

OVER  1500  NEW  WORDS  IN  THIS  EDITION 

For  this  edition  the  book  has  betn  subjected  to  a  thorough  revision  and 
entirely  reset,  adding  thousands  of  important  new  terms.  This  work  is  more 
than  a  medical  dictionary — it  is  a  Medical  Encyclopedia. 

Howard  A.  Kelly,  M.D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore 

"  Dr.  Dorland's  Dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  conve- 
nient size.     No  errors  have  been  found  in  my  use  of  it." 


Pilcher's  Practical  Cystoscopy 

Practical  Cystoscopy.  By  PAUL  M.  PILCHER,  M.D.,  Con- 
sulting Surgeon  to  the  Eastern  Long  Island  Hospital.  Octavo  of 
504  pages,  with  299  illustrations,  29  in  colors.  Cloth,  $6.00  net. 

SECOND  EDITION— published  November,  1915 

To  be  properly  equipped,  you  must  have  at  your  instant  command  the 
information  this  book  gives  you.  It  explains  away  all  difficulty,  telling  you 
•why  you  do  not  see  something  when  something  is  there  to  see,  and  telling  you 
how  to  see  it.  All  theory  has  been  uncompromisingly  eliminated,  devoting 
every  line  to  practical,  needed  every-day  facts,  telling  you  how  and  when  to 
use  the  cystoscope  and  catheter — telling  you  in  a  way  to  make  you  know. 

Bransford  Lewis,  M.  D.,  St.  Louis  University 

"  I  am  very  much  pleased  with  Dr.  Pilcher's  '  Practical  Cystoscopy.'  I  think  it  is  the 
best  in  the  English  language  now. " 


DISEASES   OF   THE  EYE. 


(Published  February,  1909) 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  DR  O.  HAAB,  of  Zurich.  Edited,  with  additions,  by  G.  E. 
DESCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology,  University  of 
Pennsylvania.  101  colored  illustrations  and  244  pages  of  text. 
Cloth,  $3.00  net.  Third  Edition.  Saunders*  Atlases. 


Haab  and  DeSchweinitz's  Ophthalmoscopy 

Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal- 
moscopic  Diagnosis.  By  DR.  O.  HAAB,  of  Zurich.  Edited, 
with  additions,  by  G.  E.  DESCHWEINITZ,  M.  D.,  Professor  of  Oph- 
thalmology, University  of  Pennsylvania.  With  152  colored  litho- 
graphic illustrations  and  94  pages  of  text.  Cloth,  $3.00  net. 
///  Saunders  Hand-Atlas  Series.  Second  Edition— April,  1909 

American  Pocket  Dictionary         New  (9th)  Edition 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited  by  W.  A. 
NEWMAN  BORLAND,  M.  D.  Containing  the  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences.  693  pages.  Flexible 
leather,  with  gold  edges,  $1.25  net;  with  thumb  index,  $1.50  net. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior. 
I  can  recommend  it  to  our  students  without  reserve." — JAMES  W.  HOLLAND,  M.  D., 
Professor  of  Medical  Chemistry  and  Toxicology  at  the  Jeferson  Medical  College,  Philadel- 
phia. Published  April,  1915 

Jackson  On  the  Eye  Preparing— New  (3d)  Edition 

A  MANUAL  OF  THE  DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF 
THE  EYE.  By  EDWARD  JACKSON,  A.  M.,  M.  D.,  Professor  of  Ophthal- 
mology, University  of  Colorado.  i2mo  of  615  pages,  with  184  illus- 
trations. 


SAUNDERS'    BOOKS    ON 


Barn  hill  and    Wales' 
Modern     Otology 

A  Text- Book  of  Modern  Otology.  By  JOHN  F.  BARN- 
HILL,  M.  D.,  Professor  of  Otology,  Laryngology,  and  Rhinology, 
and  EARNEST  DE  W.  WALES,  M.  D.,  Clinical  Professor  of 
Otology,  Laryngology,  and  Rhinology,  Indiana  University  School 
of  Medicine,  Indianapolis.  Octavo  of  598  pages,  with  31 4  original 
illustrations.  Cloth,  $5.50  net;  Half  Morocco,  $7.00  net. 

SECOND  EDITION 

This  work  represents  the  results  of  personal  experience  as  practitioners  and 
teachers,  influenced  by  the  instruction  given  by  such  authorities  as  Sheppard, 
Dundas  Grant,  Percy  Jakins,  Jansen,  and  Alt.  Much  space  is  devoted  to 
prophylaxis,  diagnosis,  and  treatment,  both  medical  and  surgical.  There  is  a 
special  chapter  on  the  bacteriology  of  ear  affections — a  feature  not  to  Le  found 
in  any  other  work  on  otology.  Great  pains  have  been  taken  with  the  illus- 
trations. A  large  number  represent  the  best  work  of  Mr.  H.  F.  Aitken. 

Frank   Allport,  M.  D., 

Professor  of  Otology,  Northwestern  University,  Chicago. 

"\  regard  it  as  one  of  the  best  books  in  the  English  language  on  this  subject.  The 
pictures  are  especially  good,  particularly  as  they  are  practically  all  original  and  not  the  old 
reproduced  pictures  so  frequently  seen."  Published  January,  1911 


Davis'  Accessory  Sinuses 

Development  and  Anatomy  of  the  Nasal  Accessory 
Sinuses  in  Man.  By  WARREN  B.  DAVIS,  M.  D.,  Corinna 
Borden  Keen  Research  Fellow  of  the  Jefferson  Medical  College, 
Philadelphia.  Octavo  of  172  pages,  with  57  original  illustra- 
tions. Published  March,  1914  Cloth,  $3.50  net. 
ORIGINAL  DISSECTIONS 

This  book  is  based  on  the  study  of  two  hundred  and  ninety  lateral  nasal 
walls,  presenting  the  anatomy  and  physiology  of  the  nasal  accessory  sinuses 
from  the  sixtieth  day  of  fetal  life  to  advanced  maturity.  It  was  necessary  for 
Dr.  Davis  to  develop  a  new  technic  by  which  the  accessory  sinus  areas  could 
be  removed  en  masse  at  the  time  of  postmortem  examinations,  and  still  per- 
mit of  reconstruction  of  the  face  without  marked  disfigurement. 


GENITO-  URINAR  Y  AND  NOSE,  THKOAT,  Etc.  g 

Greene  and  Brooks' 
Genito-Urinary  Diseases 

A  Text-Book  of  Genito-Urinary  Diseases.  By  ROBERT 
H.  GREENE,  M.D.,  Professor  of  Genito-Urinary  Surgery  at 
Fordham  University;  and  HARLOW  BROOKS,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  Medi- 
cal School.  Octavo  of  666  pages,  illustrated.  Cloth,  $5.50  net. 

FOURTH  EDITION— published  May,  1917 

This  new  work  covers  completely  the  subject  of  genito-urinary  diseases, 
presenting  both  the  medical  and  surgical  sides.  Kidney  diseases  are  very  elabo- 
rately detailed. 

New  York  Medical  Journal 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito- 
urinary diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and 
students." 


Gleason  on  Nose,  Throat, 
and  Ear 

A  Manual  of  Diseases  of  the  Nose,  Throat,  and  Ear.     By 

E.  BALDWIN  GLEASON,  M.  D.,  LL.  D  ,  Professor  of  Otology, 
Medico-Chirurgical  College,  Graduate  School  of  Medicine,  Uni- 
versity of  Pennsylvania,  Philadelphia.  12010  of  590  pages,  pro- 
fusely illustrated.  Cloth,  $2.75  net.  Published  October,  1914 

THIRD  EDITION 

Methods  of  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  essential.  A  feature  consists  of  the  collection  of  formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology  and  otology  there  ar 
few  books  which  can  be  more  heartily  commended." 

Wilcox  on  Genito-Urinary  and  Venereal  Dis- 
eases Second  Edition,  published  January.  1909 

ESSENTIALS  OF  GENITO-URINARY  AND  VENEREAL  DISEASES.  By 
STARLING  S.  WILCOX,  M.  D.,  Lecturer  on  Genito-Urinary  Diseases  and 
Syphilology,  Starling-Ohio  Medical  College,  Columbus,  Ohio.  i2mo  of 
321  pages,  illustrated.  Cloth,  $1.25  net.  In  Sounders'  Question-Corn- 
pends. 


Head's  Mouth  Infections 

Mouth  Infections.     By  JOSEPH  HEAD,  M.D.,  D.D.S.   Octavo 
of  350  pages,  with  310  illustrations. 

That  gum  and  tooth  infections  may  originate  valvular  heart  disease, 
pernicious  anemia,  arthritis  deformans,  rheumatism,  and  nervous  derange- 
ments there  is  repeated  clinical  proof.  Dr.  Head,  a  specialist  in  this  field, 
cites  case  after  case  of  organic  diseases — just  such  cases  as  come  into  your 
office  for  treatment  daily — which  he  has  traced  to  lesions  in  the  gums  due 
to  infection,  and  cured  of  both  local  and  systemic  affections.  In  this  book 
Dr.  Head  gives  you  the  principles,  the  technic  in  full,  and  his  original 
formulae  and  methods.  You  get  sections  on  diagnosis,  treatment,  mouth 
hygiene,  local  anesthesia  by  novocain,  electrolysis,  tooth  discoloration,  care 
of  children's  teeth,  orthodontia,  cement,  x-ray  study,  use  of  emetin,  and  of 
vaccines.  It  is  a  book  of  wide  and  varied  application,  of  vital  importance, 
and  of  true  scientific  value.  It  appeals  first  to  the  dentist  and  dental 
surgeon,  but  it  appeals  strongly  to  the  general  practitioner,  surgeon,  and 
specialist  because  of  the  recognized  importance  of  mouth  infection  as  factors 
in  the  etiology  of  organic  disease. 


Kyle's  Nose  and  Throat 

Diseases  of  the  Nose  and  Throat.  By  D.  BRADEN  KYLE, 
M.D.,  formerly  Professor  of  Laryngology  in  the  Jefferson  Medical 
College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist, 
and  Otologist,  St.  Agnes'  Hospital.  Octavo,  856  pages;  with 
272  illustrations  and  27  lithographic  plates  in  colors.  Cloth, 

$4.50  net  ;    Half  MorOCCO,  $6.00  net.  Published  November,  1914 

FIFTH  EDITION 

This  work  has  now  reached  its  fifth  edition.  With  the  practical  purpose 
of  the  book  in  mind,  extended  consideration  has  been  given  to  treatment,  each 
disease  being  considered  in  full,  and  definite  courses  being  laid  down  to 
meet  special  conditions  and  symptoms. 

Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book.  The  practical  man,  be  he  special  or  general,  will  not  search  ia 
vain  for  anything  he  needs." 


CHEMJSTRY  AND    DENTISTRY.  II 

Holland's 
Chemistry  and  Toxicology 

A  Text-Book  of    Medical  Chemistry   and   Toxicology, 

By  JAMES  W.  HOLLAND,  M.  D.,  Emeritus  Professor  of  Medical 
Chemistry  and  Toxicology  ,  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  678  pages,  illustrated.  Cloth,  $3.00  net. 

FOURTH  EDITION— published  April,  1915 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  thirty-five 
years'  practical  experience  in  teaching  chemistry  and  medicine.  Recognizing 
that  to  understand  physiologic  chemistry  students  must  first  be  informed  upon 
points  not  referred  to  in  most  medical  text-books,  the  author  has  included  in  his 
work  the  latest  views  of  equilibrium  of  equations,  mass-action,  cryoscopy,  os- 
motic pressure,  etc.  Much  space  is  given  to  toxicology. 

American  Medicine 

"  Its  statements  are  clear  and  terse ;  its  illustrations  well  chosen ;  its  development  logi- 
cal, systematic,  and  comparatively  easy  to  follow.  .  .  .  We  heartily  commend  the  work." 


Ivy's  Applied  Anatomy  and  Oral  Surgery 

APPLIED  ANATOMY  AND  ORAL  SURGERY  FOR  DENTAL  STUDENTS. 
By  ROBERT  H.  IVY,  M.  D.,  D.  D.  S.,  Assistant  Oral  Surgeon  to  the 
Philadelphia  General  Hospital.  1 2mo  of  290  pages,  illustrated.  Cloth, 
$1.75  net.  Second  Edition  published  July,  1917 

This  work  is  just  what  dental  students  have  long  wanted — a  concise,  practical  work 
on  applied  anatomy  and  oral  surgery,  written  with  their  needs  solely  in  mind.  No 
one  could  be  better  fitted  for  this  task  than  Dr.  Ivy,  who  is  a  graduate  in  both  den- 
tistry and  medicine.  The  text  is  well  illustrated  with  pictures  that  you  will  find  ex- 
tremely helpful. 

"I  am  delighted  with  this  compact  little  treatise.  It  seems  to  me  just  to  fill  the 
bill."— H.  P.  KUHN,  M.  D.,  Western  Dental  College,  Kansas  City. 

Oertel  on  Bright's  Disease 

THE  ANATOMIC  HISTOLOGICAL  PROCESSES  OF  BRIGHT'S  DISEASE.  By 
HORST  OERTEL,  M.  D.,  Director  of  the  Russell  Sage  Institute  of  Path- 
ology, New  York.  Octavo  of  227  pages,  with  44  illustrations  and  6 
colored  plates.  Cloth,  $5.00  net ;  Half  Morocco,  $6. 50  net. 

These  lectures  deal  with  the  anatomic  histological  processes  of  Bright's  disease,  and 
in  a  somewhat  different  way  from  the  usual  manner.  Everywhere  relations  are  em- 
phasized and  an  endeavor  made  to  reconstruct  the  whole  as  a  unit  of  interwoven 
processes.  Published  December,  1910 

"  Dr.  Oertel  gives  a  clear  and  intelligent  idea  of  nephritis  as  a  continuous  process. 
"  We  can  strongly  recommend  this  book  as  thoughtful,  scientific,  and  suggestive." — 
The  Lancet,  London. 


SAUNDERS'1    BOOKS    ON 


Goepp's  Dental  State  Boards 


Dental    State   Board   Questions  and   Answers.     By  R. 

MAX  GOEPP,  M.  D.,  Professor  of  Clinical  Medicine  at  the  Phila- 
delphia Polyclinic.     Octavo  of  428  pages.     Cloth,  $3.00  net. 

SECOND  EDITION 

This  new  work  is  along  the  same  practical  lines  as  Dr.  Goepp's  successful 
work  on  Medical  State  Boards.  The  questions  included  have  been  gathered 
from  reliable  sources,  and  embrace  all  those  likely  to  be  asked  in  any  State 
Board  examination  in  any  State.  They  have  been  arranged  and  classified  in 
a  way  that  makes  for  a  rapid  resume  of  every  branch  of  dental  practice,  and 
the  answers  are  couched  in  language  unusually  explicit — concise,  definite, 
accurate.  Published  February,  1916 


McConnell's  Pathology  arid  Bacteriology  Dental 

PATHOLOGY  AND  BACTERIOLOGY  FOR  DENTAL  STUDENTS. 
By  GUTHRIE  McCoNNELL,  M.  D. ,  Assistant  Surgeon,  Medi- 
cal Reserve  Corps,  U.  S.  N.  i2mo  of  309  pages,  illustrated. 

Cloth,  $2.25    net.  Published  March,  1915 

This  work  was  written  expressly  for  dentists  and  dental  students,  em- 
phasizing throughout  the  application  of  pathology  and  bacteriology  in 
dental  study  and  practice.  There  are  chapters  on  disorders  of  metab- 
olism and  circulation  ;  retrogressive  processes,  cell  division,  inflam- 
mation and  regeneration,  granulomas,  progressive  processes,  tumors, 
special  mouth  pathology,  sterilization  and  disinfection,  bacteriologic 
methods,  specific  micro-organisms,  infection  and  immunity,  and  labora- 
tory technic. 

Haab  and  deSchweinitz's  Operative  Ophthalmology 

ATLAS  AND  EPITOME  OF  OPERATIVE  OPHTHALMOLOGY. 
By  DR.  O.  HAAB,  of  Ziirich.  Edited,  with  additions,  by 
G.  E.  DEScHWEiNi'rz,  M.  D.,  Professor  of  Ophthalmology, 
University  of  Pennsylvania.  With  30  colored  lithographic 
plates,  154  text-cuts,  and  375  pages  of  text.  Cloth,  $3.50 
net.  In  Sounders*  Hand- Atlas  Series.  January,  IPOS 


EYE,  EAR,  NOSE,  AND  THROAT.  13 

Bass  and  Johns'  Alveolodental  Pyorrhea 

ALVEOLODENTAL  PYORRHEA.  By  CHARLES  C.  BASS,  M.D.,  Professor 
of  Experimental  Medicine,  and  FOSTER  M.  JOHNS,  M.  D.,  Instructor  in 
the  Laboratories  of  Clinical  Medicine,  Tulane  Medical  College.  Octavo 
of  168  pages,  illustrated.  Cloth,  $2.50  net.  Published  June,  1915 

This  work  discusses  alveolodental  pyorrhea  from  the  viewpoint  of  infection  by  the 
Endamoeba  buccalis  in  a  simple,  concise  way,  in  the  light  of  recent  information. 

Gleason's  Nose  and  Throat      Fourth  Edition,  Revised 

ESSENTIALS  OF  DISEASES  OF  THE  NOSE  AND  THROAT.  By  E.  B. 
GLEASON,  S.B.,  M.D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical 
College,  Graduate  School  of  Medicine,  University  of  Pennsylvania, 
Post-octavo,  241  pages,  112  illustrations.  Cloth,  $1.25  net.  In 
Saunders'  Question-Compend  Series.  Published  October,  1914 

"The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." — The  Lancet,  London. 

Grant  on  the  Face,  Mouth,  and  Jaws 

A  TEXT-BOOK  OF  THE  SURGICAL  PRINCIPLES  AND  SURGICAL  DIS- 
EASES OF  THE  FACE,  MOUTH,  AND  JAWS.  For  Dental  Students.  By 
H.  HORACE  GRANT,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical 
Surgery,  Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages, 
with  68  illustrations.  Cloth,  #2.50  net.  Published  September,  1911 

Preiswerk  and  Warren's  Dentistry 

ATLAS  AND  EPITOME  OF  DENTISTRY.  By  PROF.  G.  PREISWERK,  of 
Basil.  Edited,  with  additions,  by  GEORGE  W.  WARREN,  D.  D.  S.,  Pro- 
fessor of  Operative  Dentistry,  Pennsylvania  College  of  Dental  Surgery, 
Philadelphia.  With  44  lithographic  plates,  152  text-cuts,  and  343  pages 
of  text.  Cloth,  $3.50  net.  Saunders'  Hand- Atlases.  August,  1906 

Grunwald  and  Grayson  on  the  Larynx 

ATLAS  AND  EPITOME  OF  DISEASES  OF  THE  LARYNX.  By  DR:  L. 
GRUNWALD,  of  Munich.  Edited,  with  additions,  by  CHARLES  P. 
GRAYSON,  M.  D.,  University  of  Pennsylvania.  With  107  colored  figures 
on  44  plates,  25  text-cuts,  and  103  pages  of  text.  Cloth,  £2.50  net.  In 
Sounders'  Hand- Atlas  Series.  Published  1898 

Mracek  and  Stelwagon's  Atlas  of  Skin 

ATLAS  AND  EPITOME  OF  DISEASES  OF  THE  SKIN.  By  PROF.  DR. 
FRANZ  MRACEK,  of  Vienna.  Edited,  with  additions,  by  HENRY  W. 
STELWAGON,  M.  D.,  Jefferson  Medical  College.  With  77  colored 
plates,  50  halftone  illustrations,  and  280  pages  of  text.  Cloth,  $4.00 
net.  In  Sounders'  Hand-Atlas  Series.  Published  July,  1905 


14  SAUNDEXS''  BOOKS  ON 

Theobald's 
Prevalent  Diseases  of  the  Eye 


Prevalent  Diseases  of  the  Eye.  By  SAMUEL  THEOBALD, 
M.  D.,  Clinical  Professor  of  Ophthalmology  and  Otology,  Johns 
Hopkins  University. .  Octavo  of  550  pages,  with  219  text-illustra- 
tions and  10  plates.  Cloth,  $4.50  net ;  Half  Morocco,  $6.00  net. 

— .          *    r«-  *4    r\  Published  August,  1908 

Chas.  A.  Oliver,  M.  D., 

Clinical  Professor  of  Ophthalmology,  Woman's  Medical  College,  Phila. 
"  I  feel   I  can  conscientiously  recommend   it,  not  only  to  the  general  physician  and 
medical  student,  but  also  to  the  experienced  ophthalmologist." 


Wells'  Chemical  Pathology 

Chemical  Pathology.  By  H.  GIDEON  WELLS,  PH.D., 
M.  D.,  Professor  of  Pathology  in  the  University  of  Chicago. 
Octavo  of  616  pages.  Cloth,  $3.25  net.  Second  Edition 

Published  March,  1914 
Wm.  H.  Welch,  M.D.,  Johns  Hopkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and  I 
shall  be  glad  to  recommend  it  to  my  students." 


Stel wagon's  Essentials  of  Skin        seventh  Edition 

ESSENTIALS  OF  DISEASES  OF  THE  SKIN.  By  HENRY  W.  STEI.WAGON, 
M.  D.,  PH.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia.  Post-octavo  of  292  pages,  with  72  text-illustra- 
tions and  8  plates.  Cloth,  $1.25  net.  In  Saunders'  Question-Compend 
Series.  Published  August,  1909 

"Inline  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  cornpends  have  been 
noted." — The  Medical  News. 


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